Monitoring in critical care


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    (Hide the Philips and GE slides)
    As you can see, the BIS technology is available as a stand-alone monitor or in modular format integrated into leading patient monitoring systems.
    To monitor a patient, you will need a monitor or a module and a sensor.
    The sensor, placed on the patient’s forehead, detects the electrical activity of the brain, or EEG.
    The characteristic changes in the EEG are evaluated by the monitor’s sophisticated algorithm, and an objective measure of the sedative drug effect is displayed as the BIS value.
  • The EEG information, from which the BIS value is derived, is obtained byplacing the Sensor on the patient’s forehead
    It can be place on either side of the patient’s forehead.
    It connects to the patient interface cable
    The Sensor:
    Is an electrode strip that is designed to pick up the typically very small, or low amplitude, EEG signal
    Is designed with adhesive to give good contact with patient skin
    Has self prepping electrodes, eliminating extensive skin preparation. Each of the electrodes contains a pre-filled conductive gel to allow for conduction of the EEG signal
    Has a 4th electrode placed over the eye which improves artifact/EMG resistance (usually secondary to patient muscle movement) for a more accurate and precise measure of sedation
    Reads the frontal montage – single channel EEG
    Is Single-use, to be changed every 24 hours. The Extend Sensor has date/time area to record time of sensor application
    Is Latex-free
  • Ref: Ingento EP and Drazen J: Mechanical ventilators, in Hall JB, Scmidt GA, and Wood LDH(eds.): Principles of Critical Care. New York, McGraw-Hill, Inc., 1992, p.146.
    (Would we also want to put slides with pressure mode graphs as well to show the different flow characteristics ??)
    During SIMV, the ventilator divides time by the set rate to determine cycle-length. During the early part of this cycle, the patient may breath spontaneously without support. During the terminal phase of this cycle (% varies by manufacturer) the ventilator will synchronize a full breath with detected effort by the patient.
  • Monitoring in critical care

    1. 1. Co-ordinator:- Dr. Navab Singh(M.D) Speaker:- Dr. Uday Pratap
    2. 2. • Sickest patients (multiple diagnosis, multi organ failure, immunocompromised, septic and trauma) • Move less • Malnourished • More obtunded (Glasgow coma scale) • May be associated Diabetics and Heart failure
    3. 3.  “Repeated or continuous observations or measurements of the patient, physiological function, and the function of life support equipment, for the purpose of guiding management decisions, including when to make therapeutic interventions, and assessment of those interventions”  A patient monitor may not only alert caregivers to potentially lifethreatening events; many provide physiologic input data used to control directly connected life-support devices.
    4. 4.  There are at least four categories of patients who need physiologic monitoring:  1. Patients with unstable physiologic regulatory systems; for example, a patient whose respiratory system is suppressed by a drug overdose or anesthesia.  2. Patients with a suspected life-threatening condition; for example, a patient who has findings indicating an acute myocardial infarction (heart attack).  3. Patients at high risk of developing a life-threatening condition; for example, patients immediately post open-heart surgery, or a premature infant whose heart and lungs are not fully developed.  4. Patients in a critical physiological state; for example, patients with multiple trauma or septic shock.
    5. 5.  Common to all patients ◦ Pulse oxymetry ◦ BP monitoring ◦ Non invasive  Invasive  CVP ◦ ◦ ◦ ◦ ECG Temprature Urine output ABG
    6. 6. ICP monitoring  GCS scoring  Spinal cord fn monitoring  BIS monitor  EEG 
    7. 7. BIS Technology BIS Monitor BIS Modules BIS Sensor
    8. 8. Sensor Application Apply sensor on forehead at angle Circle #1: Centered, 2 inches above nose Circle #4: Directly above eyebrow Circle #3: On temple, between corner of eye and hairline Press around the edges of each circle to assure adhesion Press each circle for 5 seconds
    9. 9. Level of consciousness  Pupils  ◦ Size ◦ Reactivity ◦ Equality  Cerebral perfusion pressure (>70mmHg) ◦ CPP = MAP- ICP  Intracranial pressure (<10mmHg)
    10. 10. Mixed venous saturation ◦ Measured with PA catheter ◦ Normal is 65-75% ◦ Low SvO2 may indicate inadequate tissue O2 delivery (even if arterial O2 is OK) Lactates ◦ Increased lactate concentration and metabolic acidosis suggests anaerobic metabolism and inadequate tissue oxygenation. lactate also increases with liver failure and sepsis,  ABG monitoring ◦ Monitors acid-base balance, PaO2, and PaCO2   Gastric tonometry Used to detect shock-induced splanchnic ischemia by measure gastric luminal PCO2 and deriving the mucosal pH
    11. 11. PA catheter  TEE  JVP  CO monitor 
    12. 12.  NM- monitor: standard method of monitoring drug induced NM block is to apply a series of four low frequency(2Hz) electrical pulse to ulnar nerve at forearm, and observe for adduction of thumb. Total absence of thumb adduction is evidence of excessive block. Desired goal is 1or 2 preceptible twitches, and drug infusion is adjusted to achieve end point.  Capnography ◦ End-tidal CO2 concentration is close to artrial PaCO2 levels ◦ Indicates the adequacy of alveolar ventilation  Pain scoring  Spirometry  Plasma level of various drugs  X-ray chest
    13. 13.  Global measures ◦ Reflect the adequacy of total tissue perfusion but could be normal with local perfusion abnormalities ◦ SvO2 <55% indicates global tissue hypoxia.  Organ-specific Measures ◦ Urine flow  A sensitive indicator of renal perfusion provided the kidneys aren’t damaged  Normal is 1ml/kg ◦ Core-peripheral temperature  The gradient between peripheral (skin) temp and core (rectal) is often used as an index of peripheral perfusion  The less perfusion, the colder the periphery
    14. 14. Dr.T.V.Rao MD 02/07/14 16
    15. 15. 1- Acute respiratory failure due to:  Mechanical failure, includes neuromuscular diseases as Myasthenia Gravis, Guillain-Barré Syndrome, and Poliomyelitis (failure of the normal respiratory neuromuscular system)  Musculoskeletal abnormalities, such as chest wall trauma (flail chest) Infectious diseases of the lung such as pneumonia, tuberculosis. 2- Abnormalities of pulmonary gas exchange as in:  Obstructive lung disease in the form of asthma, chronic bronchitis or emphysema.  Conditions such as pulmonary edema, atelectasis, pulmonary fibrosis.  Patients who has received general anesthesia as well as post cardiac arrest patients often require ventilatory support until they have recovered from the effects of the anesthesia or the insult of an arrest.
    16. 16. Parameters Ventilation indicated Normal range 35 < 10-20 5> 10 -8 15 > 65-75 25-> 75-100 A- Pulmonary function :studies • Respiratory rate (breaths/min). • Tidal volume (ml/kg body wt) • Vital capacity (ml/kg body wt) • Maximum Inspiratory Force (cm HO2)
    17. 17. Parameters Ventilation indicated Normal range 7.25 > 60 > 50 < 7.35-7.45 75-100 35-45 B- Arterial blood Gases • PH • PaO2 (mmHg) • PaCO2 (mmHg)
    18. 18. Negative-pressure ventilators  Early negative-pressure ventilators were known as “iron lungs.”  The patient’s body was encased in an iron cylinder and negative pressure was generated .  Intermittent short-term negative-pressure ventilation is sometimes used in patients with chronic diseases.  The iron lung are still occasionally used today.  Positive-pressure ventilators are deliver gas to the patient under positive-pressure, during the inspiratory phase.
    19. 19. A- Volume Modes 1- Assist-control (A/C) 2- Synchronized intermittent mandatory ventilation (SIMV) B- Pressure Modes 1. Pressure-controlled ventilation (PCV) 2- Pressure-support ventilation (PSV) 3- Continuous positive airway pressure (CPAP) 4- Positive end expiratory pressure (PEEP) 5- Noninvasive bilevel positive airway pressure ventilation (BiPAP)
    20. 20.  ventilator provides the patient with a pre-set tidal volume at a pre-set rate .  Patient may initiate a breath on his own, but the ventilator assists by delivering a specified tidal volume to the patient. pt can initiate breaths that are delivered at the preset tidal volume.  Pt. can breathe at a higher rate than the preset number of breaths/minute.  The total respiratory rate is determined by the number of spontaneous inspiration initiated by the patient plus the number of breaths set on the ventilator.  In A/C mode, a mandatory (or “control”) rate is selected.  If the patient wishes to breathe faster, pt. can trigger the ventilator and receive a full-volume breath.
    21. 21.  Often used as initial mode of ventilation  When the patient is too weak to perform the work of breathing (e.g., when emerging from anesthesia). Disadvantages:  Hyperventilation,
    22. 22.  The ventilator provides the patient with a pre-set number of breaths/minute at a specified tidal volume and FiO2.  In between the ventilator-delivered breaths, the patient is able to breathe spontaneously at his own tidal volume and rate with no assistance from the ventilator.  However, unlike the A/C mode, any breaths taken above the set rate are spontaneous breaths taken through the ventilator circuit .  The tidal volume of these breaths can vary drastically from the tidal volume set on the ventilator, because the tidal volume is determined by the patient’s spontaneous effort.
    23. 23.  Adding pressure support during spontaneous breaths can minimize the risk of increased work of breathing.  Ventilators breaths are synchronized with the patient spontaneous breathe( no fighting).  Used to wean the patient from the mechanical ventilator.  Weaning is accomplished by gradually lowering the set rate and allowing the patient to assume more work
    24. 24. Ingento EP & Drazen J: Mechanical Ventilators, in Hall JB, Scmidt GA, & Wood LDH(eds.): Principles of Critical Care
    25. 25.  Ventilation is completely provided by the mechanical ventilator with a preset tidal volume, respiratory rate and oxygen concentration  Ventilator totally controls the patient’s ventilation i.e. the ventilator initiates and controls both the volume delivered and the frequency of breath.  Client does not breathe spontaneously.  Client can not initiate breathe
    26. 26.  The PCV mode is used ◦ If compliance is decreased and the risk of barotrauma is high. ◦ It is used when the patient has persistent oxygenation problems despite a high FiO2 and high levels of PEEP.  The inspiratory pressure level, respiratory rate, and inspiratory– expiratory (I:E) ratio must be selected.
    27. 27.  Sedation and the use of neuromuscular blocking agents are frequently indicated, because any patient–ventilator asynchrony usually results in profound drops in the SaO2. This is especially true when inverse ratios are used. The “unnatural” feeling of this mode often requires muscle relaxants to ensure patient–ventilator synchrony.  Inverse ratio ventilation (IRV) mode reverses this ratio so that inspiratory time is equal to, or longer than, expiratory time (1:1 to 4:1).  Inverse I:E ratios are used in conjunction with pressure control to improve oxygenation by expanding stiff alveoli by using longer distending times, thereby providing more opportunity for gas exchange and preventing alveolar collapse.
    28. 28.  The patient breathes spontaneously while the ventilator applies a predetermined amount of positive pressure to the airways upon inspiration.  Pressure support ventilation augments patient’s spontaneous breaths with positive pressure boost during inspiration i.e. assisting each spontaneous inspiration.  Helps to overcome airway resistance and reducing the work of breathing.  Indicated for patients with small spontaneous tidal volume and difficult to wean patients.  Patient must initiate all pressure support breaths.  Pressure support ventilation may be combined with other modes such as SIMV or used alone for a spontaneously breathing patient.
    29. 29.  The patient’s effort determines the rate, inspiratory flow, and tidal volume.  In PSV mode, the inspired tidal volume and respiratory rate must be monitored closely to detect changes in lung compliance.  It is a mode used primarily for weaning from mechanical ventilation.
    30. 30.  Constant positive airway pressure during spontaneous breathing  CPAP allows the nurse to observe the ability of the patient to breathe spontaneously while still on the ventilator.  CPAP can be used for intubated and nonintubated patients.  It may be used as a weaning mode and for nocturnal ventilation (nasal or mask CPAP)
    31. 31.  Positive pressure applied at the end of expiration during mandatory ventilator breath
    32. 32.  Prevent atelactasis or collapse of alveoli  Treat atelactasis or collapse of alveoli  Improve gas exchange & oxygenation  Treat hypoxemia refractory to oxygen therapy.(prevent oxygen toxicity  Treat pulmonary edema ( pressure help expulsion of fluids from alveoli
    33. 33.  BiPAP is a noninvasive form of mechanical ventilation provided by means of a nasal mask or nasal prongs, or a full-face mask.  The system allows the clinician to select two levels of positivepressure support:  An inspiratory pressure support level (referred to as IPAP)  An expiratory pressure called EPAP (PEEP/CPAP level).
    34. 34. 1- T-piece trial, 2- Continuous Positive Airway Pressure (CPAP) weaning, 3- Synchronized Intermittent Mandatory Ventilation (SIMV) weaning, 4- Pressure Support Ventilation (PSV) weaning.
    35. 35.  Awake and alert  Hemodynamically stable, adequately resuscitated, and not requiring vasoactive support  Arterial blood gases (ABGs) normalized or at patient’s baseline - PaCO2 acceptable - PH of 7.35 – 7.45 - PaO2 > 60 mm Hg , - SaO2 >92% - FIO2 ≤40%  Positive end-expiratory pressure (PEEP) ≤5 cm H2O  Vt 5 ml / kg  VC > 10- 15 ml / kg  PEP (positive expiratory pressure) > - 20 cm H2O ( indicates patient’s ability to take a deep breath & cough),
    36. 36. ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ Catecholamines Glucocorticoids and Mineralocorticoids Insulin Glucagon Thyroid hormone Growth hormone Parathyroid hormone
    37. 37.  Movement  Sequential Compression Devices  Pharmacologic treatment ◦ UFH decrease incidence of DVT by 20%.(initial bolus dose of 80 IU/kg and follow with continuous infusion of 18IU/kg/hr, check PTT 6hr after start of infusion) ◦ LMWH decrease incidence of DVT by 30% over UFH .
    38. 38.  Type of fluid that is best designed to correct a specific problem with fluid balance is:  Crystalloid fluids are designed to fill extracellular space are would be use in pt. With dehydration, (loss of interstitial &intravascular fluid).  Colloid fluid are designed to expand the plasma volume and are appropriate for pt. With hypovolemia due to blood loss.  Albumin containing colloid fluid are appropriate for pt. With hypovolemia associated with hypoalbuminemia.
    39. 39.  Regular oral and teeth cleaning should be done at lest 12 hrly.  Prevent aspiration 1. Positioning—lateral position with head turned to the side or side-lying. Position back of head on a pillow so that the face tips forward and fluid/ secretions will flow out of the mouth, not back into the throat. Place a bulb syringe or suction machine with suction equipment nearby. Care of eyes :  Clean from inner to outer conthus with wet (normal saline), warm cotton ball or compress.  Use artificial tear solution or normal saline every four hour, if blink reflex is absent.  Care for eye glass, contact lens.
    40. 40.  Repositioning the ETT move it to a different location on the patient’s mouth avoiding areas of breakdown and ulceration.  Skin preparation is required when using tapes or devices with adhesives. This may include: -Shaving (consent may be required before shaving), cleaning and drying. - Preparation with skin prep solutions such antiseptic.  If an ETT requires advancing or withdrawing, the patient’s oral airway should be suctioned and then the cuff deflated prior to moving the ETT.  ETT cuff pressure is monitored to minimize the risk of tracheal necrosis and to reduce aspiration of oral secretions into the airway.
    41. 41.  ETT cuff pressure should be maintained at a minimum of 25 cmH2O to reduce the risk of secretions leaking into the trachea and bronchi.  Maximum cuff pressure is 30 cmH20 to avoid the risk of tracheal necrosis.  The measuring device connects to the one way valve of the ETT pilot balloon and the pressure is read at end of inspiration.  ETT suctioning should be performed at least 4-6hrly to ensure airway patency.  Perform hand hygiene prior to using the in-line suction.  Always wear gloves and eye protection.
    42. 42.  Suctioning is the mechanical aspiration of pulmonary secretions from a patient with an artificial airway in place.  Indications ◦ Inability to cough effectively ◦ Sputum plugging  To assess tube patency  Contraindication  Frank haemoptysis  Severe brochospasm  Undrained pneumothorax  Compromised cardiovascular system
    43. 43.  The suction catheter used must be less than half the diameter of endotracheal tube.  The vacuum pressure should be as low as possible. (60-150mmHg)  Suction should never be routine, only when there is an indication  Hazards of suctioning Mucosal trauma Cardiac arrhythmias Hypoxia Raised intracranial pressure    
    44. 44.  To be given every four hours  Skin around tracheostomy tube cleaned with betadine  Inner cannula of metal tracheostomy -cleaned under running water -immersed in hydrogen peroxide for 10mts - washed with water and gauze wick -boiled for 10 mints and replaced once It is cool
    45. 45.  Nosocomial infections ◦ occur in approximately 10% of ICU patients at a rate of 21 to 25 infections per 1000 ICU patient-days. ◦ The most common nosocomial infections in medical ICUs are urinary tract infections (31%), followed by pneumonia (27%) and primary bloodstream infections (19%).
    46. 46.  VAP is defined as pneumonia developing in mechanically ventilated patients after more than 48 hours of intubation, with no clinical evidence suggesting the presence or probable development of pneumonia at the time of initial intubation.  VAP is a leading cause of morbidity and mortality in mechanically ventilated, critically ill patients.
    47. 47.  The incidence of VAP is estimated to be 10% to 25%, and the estimated mortality rate from VAP is 5% to 27%. VAP also increases hospital length of stay and cost.  The diagnosis of VAP is challenging. presumptive diagnosis of pneumonia is made when fever, leukocytosis, purulent secretions, and a new infiltrate on chest radiography develop and when bacteria are isolated by nonquantitative analysis of endotracheal aspirates.  These nonspecific diagnostic criteria may lead to unnecessary antibiotic use, increased hospital cost, emergence of resistant microorganisms, and a potential delay in diagnosis of the true cause of the fever.
    48. 48. Host Factors Factors that facilitate reflux & aspiration into the lower RT • Elderly • Severe Illness • Underlying Lung Disease - Mechanical ventilation • Depressed Mental Status - Tracheostomy • Immunocompromising - Use of a Nasogastric Tube Conditions or Treatments - Supine Position • Viral Respiratory Tract Factors that impede normal Infection Pulmonary Toilet Colonisation - Abdominal or thoracic surgery • Intensive Care Setting - Immobilisation • Use of Antimicrobial Agents • Contaminated hands • Contaminated Equipment 02/07/14 Dr.T.V.Rao MD 52
    49. 49.  Early onset VAP is caused by Streptococcus pneumonia, H influenza, Moraxella catarrhalis and methicillin-sensitive Staphylococcus aureus (MSSA).  Late onset VAP is caused commonly by Pseudomonas aeruginosa, Acinetobacter, Enterobacter species and methicillin resistant staphylococcus aureus (MRSA).  VAP is frequently polymicrobial and gram negative bacilli are the predominant organism’s isolated.
    50. 50.  Prevention of Ventilator-Associated Pneumonia Gastric pH  The use of sucralfate, an agent that does not increase gastric pH, may be preferable to H2 receptor antagonists or proton pump inhibitors. Three studies found decreased mortality rates in patients treated with sucralfate rather than H 2 receptor antagonists or proton pump inhibitors. Positioning  Positioning of the head of the bed at 30 degrees is the most cost-effective intervention for prevention of VAP. This position results in decreased gastroesophageal reflux. Subglottic Aspiration of Secretions  Pooling of secretions above the endotracheal tube cuff may increase the volume of bacteria that enter the airways. Removal of these secretions by continuous aspiration in the subglottic region requires the use of a specialized endotracheal tube with a second lumen that permits a suction catheter to exit proximal to the endotracheal tube cuff.
    51. 51.   Aminoglycosides and quinolones are bactericidal in a concentration dependent fashion.  In addition these agents have a prolonged postantibiotic effect (PAE), allowing them to suppress bacterial growth even after their concentrations are below target level.  vancomycin and the beta-lactams (penicillins, cephalosporins, aztreonam) are also bactericidal but act in a time-dependent rather than in a concentrationdependent fashion, do not possess significant postantibiotic effect against gram negative bacilli,  Generally speaking, empirical therapy should be commenced once NP is suspected and altered as microbiologic data become available
    52. 52.  Catheter-Related Bloodstream Infections  It is estimated that more than 5 million CVCs are inserted every year in the United States. Unfortunately, more than 15% of patients have complications from these lines. Infectious complications are reported to occur in 5% to 26% of patients with CVCs. The mortality rate attributable to CRBSIs ranges from 12% to 25%,         Prevention of Central Venous Catheter Infections Antibiotic-Impregnated Central Venous Catheters Examine the efficacy of antimicrobial-impregnated catheters in an effort to decrease the incidence. CVCs coated with the antimicrobials chlorhexidine and silver sulfadiazine or impregnated with the antibiotics minocycline and rifampin are commercially available. Chlorhexidine/sulfadiazine-coated catheters lowered the rate of bloodstream infection from 7.6 to 1.6 infections per 1000 catheter-days (P = .03).
    53. 53.         The use of antimicrobial-impregnated catheters should be considered in all critically ill patients who require long-term (at least 3 days) indwelling central venous access. Immunocompetent patients who will be catheterized for less than 3 or 4 days may not need these catheters because infection is rare during this period. Sterile Technique Optimal sterile technique is the most cost-effective means of reducing the incidence of central line colonization and CRBSI. Use of maximal sterile barrier precautions such as mask, cap, sterile gown, sterile gloves, and a large sterile drape. Use of chlorhexidine solution for skin decontamination reduces the risk of catheter colonization and is therefore preferred over the use of povidoneiodine solution. Ultrasound Guidance With the development of portable, inexpensive ultrasound machines, for reducing the complications associated with central venous cannulation .
    54. 54.  Ultrasound guidance has been shown to reduce the number of complications, unsuccessful attempts, and time required for insertion of an internal jugular vein catheter,  Clinical trials assessing whether use of ultrasound can decrease the incidence of central venous line infections remain to be completed, but this technology can decrease the number of attempts required to locate the internal jugular vein and should be used routinely when available. Duration  The need for a CVC should be reassessed daily, and unnecessary catheters should be removed because the probability of catheter-related infections increases with time.  The risk of infection with catheterization stays relatively low until about the fifth to seventh days and then increases.
    55. 55. Establishment In of pain as 5th vital sign - frequent evaluations cognitive impairment /delirium markers - behavioural (facial-FACS) - physiological-BP,HR,RR Creative assessments - teaching hand movements / blinking Subjective quantification numeric/graphic scales (W-B faces)
    56. 56.  Treatment of perceived & prevention of anticipated pain  Opiates – principal agents in ICU - potent / lack of ceiling effects - mild anxiolytic & sedative - relieves air hunger & suppress cough in resp failure - improved patient – ventilator synchrony - effective antagonist - naloxone  Lack amnesic effects /additional sedatives required
    57. 57.  Morphine & Hydromorphine  accumulation of metabolites  Pethidine - only for shivering/ drug induced rigors  Codeine/oxycodone – oral - not effective  Methadone for c/c pain/ complex pain syndromes  Fentanyl / sufentanil/ remifentanil/ alfentanil  popular  Flexibility of choice essential
    58. 58.  In the agitated, ventilated & for procedure discomfort  To avoid self extubation & removal of catheters  NM blockade mandates analgesia & sedation  Control of pain before sedation  All have side effects – dose dependent   Analgesics are not sedatives/ Sedatives are not analgesics
    59. 59.  Benzodiazepines most popular for sedation  Short term sedation – midazolam<3h (amnesic/ hypotension) - propofol – infusion syndrome/ pancreatitis  Long term – lorazepam<20h /diazepam>96h (not for infusion)  Delirium – haloperidol - neurolept syndrome/torsade pointes  Antagonist- flumazenil 0.2mg-1mg (withdrawal seizures)
    60. 60.  Dexmedetomidine- ∝2 agonist/ GABA sparing effects  Short term analgesia, sedation, anxiolysis  No cardio-respiratory depression/ easily arousable  Continuous infusion in ventilated /prior,during &post- extbn  No amnesia/ crosses placenta/  Antagonised by atipamezole – combinations useful in ICU
    61. 61.  Assess levels to vary according to course of ICU stay  Observational scales - 4 levels – min, mod, deep, GA  Ramsay sedation scale 1-6 (vocal, glabellar tap)--aim for 3-4  Direct information- ideal to assess analgesia & sedation  BIS – for deep sedated & paralysed
    62. 62. Pancuronium Rocuronium Cisatracuriu m Dose (mg/kg) 0.1 0.6-1 0.1-2 Duration (min) 60-100 30-40 35-50 Infusion (micro grm/kg/min) 1-2 10-12 2.5-3 Effect on HR Tachycardia Mild increase at high dose None Effect on renal failure Prolong effect of drug n metabolites Mild prolonged minimal none prolonged none Effect on hepatic failure
    63. 63.  Cleaning more Important than Disinfection and Sterilization  Cleaning Removes contaminants, Dust, organic matter, Disinfection Reduces number of microbes
    64. 64.  Sterilization is absolute, removes microbes and spores too.  To achieve Sterilization is Expensive, not sustainable, many times not needed.  An effective Disinfection reduces the infections drastically.
    65. 65.  To Sterilization of ICU formaldehyde gas (bactericidal & sporicidal,viricidal) is widely employed as it is cheaper for sterilization of huge areas like operation theatres and ICU.  Formaldehyde kills the microbes by alkylating the amino acids and sulfydral group of proteins and purine bases.  In spite of the gas being hazardous continues to be used in several developing countreis
    66. 66. Single closed cubicle Cases – open tb , anthrax, MARSA etc… Uv light for disinfection
    67. 67.  A Chemical compound VIRKON gaining importance as non Aldehyde compound.  Virkon proved to be safe Virucidal Bactericidal, Fungicidal Mycobactericidal used as : As a Chemical disinfectant. Disinfects Medical devices. Disinfects Laboratory equipment. Decontaminate spillages with Blood and body fluids. Finding usefulness in replacing autoclaving and saving time.      
    68. 68.  Sterile water for nebulizer & humidifier  Pneumatic circuit to be changed when visibly soiled  Use heat & moisture exchange filter   Condensate in tubing to be drained only to the water traps Humidifier domes (auto claved or sterilized by 2% glutaraldehyde)
    69. 69. Washed under running water Immersed in 2% glutaraldehyde for 8 to 10hrs
    70. 70.  Negative Air pressure vented to the operation theatre.  Environmental cleaning should be twice daily
    72. 72.  Critically Ill (Frequent Position changes, )  Stable (Progressive tilting & Ambulation)
    73. 73.  ICU rehabilitation has been shown to accelerate recovery.  Early mobilization for unconscious patients starts right from turning the patient every two hours.  Graded exercises can be started as soon as the patient regains consciousness.  Activity is required to maintain sensory input, comfort, joint mobility and healing ability .  Activity minimizes the weakness caused by loss of up to half the patients muscle mass.  Graded ambulation can be started depending on patients condition
    74. 74.  A treatment intervention employed for improving pulmonary hygiene including positioning, chest percussion, vibration and manual hyperinflation to assist in mobilizing secretions in the lungs from the peripheral airways into the more central airways so that they can be expectorated or suctioned.  Prevent accumulation of secretions  Improve mobilization and drainage of secretions  Promote relaxation to improve breathing patterns
    75. 75.  Prophylactic - Pre-operative high risk surgical patient - Post-operative patient who is unable to mobilize secretions - Neurological patient who is unable to cough effectively - Patient receiving mechanical ventilation who has a tendency to retain secretions - Patients with pulmonary disease, who needs to improve bronchial hygiene
    76. 76.  Therapeutic - Atelectasis due to secretions - Retained secretions - Abnormal breathing pattern due to primary or secondary pulmonary dysfunction - COPD and resultant decreased exercise tolerance - Musculoskeletal deformity that makes breathing pattern and cough ineffective
    77. 77. Thank you
    78. 78.  Decreased minute ventilation ◦ Respiratory rate ◦ Tidal volume  Treatment: ◦ Increase respiratory rate: assure I-time not too short as rate increased ◦ Increase tidal volume ◦ Allow permissive hypercarbia
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