WELCOME AND GREETINGS TO ALL
Corridor….
Inside ICU
Inside ICU
ICU Beds Inside
Inauguration…..
ICU
What does it mean???
Intensive care units (ICU),
also called
critical care unit or
intensive therapy unit or
Intensive...
ICU Are sections within a
hospital
That look after patients:
whose conditions are life-threatening and
need constant, clos...
A person in an ICU needs constant medical
attention and support to keep their body
functioning.
They may be unable to brea...
Intensive care is often needed
when one or more of your organ
systems have failed.
For example, this might be your:
• lung...
Conditions and situations that can
cause your organ systems to fail
• a serious accident – such as a road
accident or a se...
Cont…..
• a serious infection – (SIRS) such as
a severe case of pneumonia (inflammation
of the lungs) or sepsis(blood pois...
Intensive care units (ICUs)
contain a variety of specialized
equipments, which may vary
from one unit to another.
A series...
Main ICU machines
Ventilator
Monitoring equipments
• heart and pulse rate (measured by an
electrocardiogram or ECG)
• air ...
Main ICU machines (Cont…)
IV lines and pumps
• sedatives – to reduce anxiety and
encourage you to sleep
• antibiotics – me...
Main ICU machines (Cont…)
Kidney support
Respiratory support
Feeding tube
Drains
Catheters
Suction pumps
Others
Recovery
Once you are able to breathe unaided, and you
no longer need intensive care and you will be
transferred to a diff...
Common recovery problems
Severe weakness and tiredness
Loss of weight and muscle strength
Weak voice
Inability to grip sma...
Levels of Care
"Comprehensive Critical Care" defined four
different levels of care:
• Level-0
Patients whose needs can be ...
Levels of Care (Cont..)
Level-3
Patients requiring advanced respiratory
support alone or basic respiratory support
togethe...
Historical Backgrounds of ICU
concepts
800 BC: Prophet Elisa- mouth to mouth…
460-70 BC: Hipocrates- 1st Endo-tracheal
Int...
Historical Backgrounds of ICU
concepts (Cont…)
High pressure-tension pneumothorax…
1837: manual compression of chest…
1864...
Historical Backgrounds of ICU
concepts (Cont…)
Later developed cuirass
All these (tank & cuirass) were negative
pressure v...
Historical Backgrounds of ICU
concepts (Cont…)
1952: Denmark (severe epidemics)- Ambu
by medical students plus tank and cu...
Mechanical Ventilation (1)
• Use of a machine to take over active
breathing for a patient
• Used for patients who are unab...
Ventilator in RpMCH ICU
Mechanical Ventilation (2)
Goals:
•
Increase efficiency of breathing
•
Increase oxygenation
•
Improve ventilation/perfusio...
Mechanical Ventilation (Indications)
A) Established Acute Respiratory Failure
 Primary ventilatory failure
– Poisonings w...
Mechanical Ventilation (Indications)
B) Incipient Respiratory Failure
 Obese patients who have undergone upper abdominal
...
Commonly used modes of
mechanical ventilation
•
•
•
•
•
•
•
•

Controlled mandatory ventilation (CMV)
Assist control venti...
Monitoring Mechanics
Pressure, flow, and volume
Time‐ based graphics (waveforms)
– Pressure
– Flow
– Volume
Derived measur...
analgesia

Sedation

Muscle
relaxation

Nutrition

Care of a patient on
respiratory support

Preventing
complications
Ches...
Pulmonary
Pulmonary barotrauma
Chest infection
Venous thrombosis
Pulmonary embolism
Lung fibrosis (late)
Alveolar hyperven...
Weaning
• Process of withdrawal of mechanical
ventilatory support that transfers the work of
breathing from ventilator to ...
Increased cost

Increased
risk of VAP

Decreases the
availability of ICU
beds

Why Wean
early ???

Increased hospital
leng...
Weaning Criteria
Clinical Criteria
• Adequate cough
• Absence of
excessive
tracheobronchial
secretions
• Resolution of the...
Basic monitoring requirements
for seriously ill patients
•
•
•
•
•
•
•

Heart rate
Blood pressure
Respiratory rate
Pulse o...
Non-Invasive Monitoring
– Clinical variables
– BP
– ECG
– Echocardiography
– Esophageal doppler
– Gastric tonometry
Invasive Monitoring
– Arterial line
– Systolic pressure variation
– Central venous pressure
– Pulmonary artery catheteriza...
Maintaining Homeostasis to
allow time for recovery

Continuous or repeated observation +
vigilance in order to maintain ho...
Standard ICU personnel
Crit Care Med 2003; 31(11):2677–2683
• Vary significantly from hospital to hospital
• With respect ...
Standard ICU personnel (cont..)
Crit Care Med 2003; 31(11):2677–2683
Large medical centers frequently have multiple
ICUs:
...
ICU personnel in RpMCH
No post of Doctors till now….(needs post
creation)
Inadequate trained nurses…..
No organizational (...
ICU admission Criteria
(Adapted from McQuillan et al BMJ
1998;316:1853-8.)
• Threatened airway
• All respiratory arrests
•...
ICU admission Criteria (Cont)
(Adapted from McQuillan et al BMJ
1998;316:1853-8.)
• Systolic blood pressure <90 mm Hg
• Su...
Multidisciplinary Approach
Acute organ failure (Recoverable)- ICU
Main disease- concerned to respective
department
Any add...
Mortality rate and expectations
Rigon et al. Critical Care 2006 10:R5 doi:10.1186/cc3921

Characteristic
Overall populatio...
Brain death and Medicolegal
Aspects
• Cardiac death:
– Heartbeat and breathing stop

• Brain death:
– Irreversible cessati...
Organ donation
• Call LifeLink for all deaths
– Donor or not in your eyes
– Tissue – bone, corneas, heart valves

• Mentio...
References
1.
2.

Egan’s – Fundamentals of Respiratory Care 9th ed.
International Anaesthesiology Clinics – Update on
resp...
ICU of Rangpur Medical College Hospital
ICU of Rangpur Medical College Hospital
ICU of Rangpur Medical College Hospital
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ICU of Rangpur Medical College Hospital

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  • Premature weaning carries its own set of problems, including difficulty in re-establishing artificial airway, compromised gas exchange, high incidence of nosocomial pneumonia and 6 to 12 fold increased mortality risk.
  • Objective measures that assess a patient’s ability to resume spontaneous ventilation, maintain adequate arterial oxygenation, clear tracheobronchial secretions, and protect the airway from aspiration
  • ICU of Rangpur Medical College Hospital

    1. 1. WELCOME AND GREETINGS TO ALL
    2. 2. Corridor….
    3. 3. Inside ICU
    4. 4. Inside ICU
    5. 5. ICU Beds Inside
    6. 6. Inauguration…..
    7. 7. ICU What does it mean??? Intensive care units (ICU), also called critical care unit or intensive therapy unit or Intensive Treatment Unit (ITU)
    8. 8. ICU Are sections within a hospital That look after patients: whose conditions are life-threatening and need constant, close monitoring and support from equipment and medication to keep normal body functions going.
    9. 9. A person in an ICU needs constant medical attention and support to keep their body functioning. They may be unable to breathe on their own and have multiple organ failure. Medical equipment will take the place of these functions while the person recovers.
    10. 10. Intensive care is often needed when one or more of your organ systems have failed. For example, this might be your: • lungs • kidneys • heart • digestive system
    11. 11. Conditions and situations that can cause your organ systems to fail • a serious accident – such as a road accident or a severe head injury • a serious acute (short-term) health condition – such as a heart attack (where the supply of blood to the heart is suddenly blocked), or a stroke (where the blood supply to the brain is interrupted)
    12. 12. Cont….. • a serious infection – (SIRS) such as a severe case of pneumonia (inflammation of the lungs) or sepsis(blood poisoning) • major surgery – this can either be a planned admission to an ICU as part of your recovery after surgery or an emergency measure if there are complications during surgery
    13. 13. Intensive care units (ICUs) contain a variety of specialized equipments, which may vary from one unit to another. A series of tubes, wires and cables connect the patient to various equipments, which may look alarming at first. Sounding and beeping of these may puzzle the patient and attendants.
    14. 14. Main ICU machines Ventilator Monitoring equipments • heart and pulse rate (measured by an electrocardiogram or ECG) • air flow to your lungs • blood pressure and blood flow • pressure in your veins (known as central venous pressure or CVP) • the amount of oxygen in your blood • your body temperature
    15. 15. Main ICU machines (Cont…) IV lines and pumps • sedatives – to reduce anxiety and encourage you to sleep • antibiotics – medication that is usually given in high doses and used to treat infections caused by bacteria • analgesics – also known as painkillers • Inotropes • Insulin
    16. 16. Main ICU machines (Cont…) Kidney support Respiratory support Feeding tube Drains Catheters Suction pumps Others
    17. 17. Recovery Once you are able to breathe unaided, and you no longer need intensive care and you will be transferred to a different ward to continue your recovery. (HDU) Only Recoverable, acute condition patients are suitable candidate for ICU. Chronic, end stage diseases are not usually suitable…….
    18. 18. Common recovery problems Severe weakness and tiredness Loss of weight and muscle strength Weak voice Inability to grip small items Feeling depressed Cognitive function
    19. 19. Levels of Care "Comprehensive Critical Care" defined four different levels of care: • Level-0 Patients whose needs can be met through normal ward • Level-1 Patients at risk of their condition deteriorating, or higher levels of care whose needs can be met on advice and support from the critical care team. • Level-2 Patients requiring more detailed observation or intervention, single failing organ system or postoperative care, and higher levels of care.
    20. 20. Levels of Care (Cont..) Level-3 Patients requiring advanced respiratory support alone or basic respiratory support together with support of at least two organ systems. This level includes all complex patients requiring support for multi-organ failure. High dependency can refer to level 1 or 2 whereas intensive care usually means level 2 or 3.
    21. 21. Historical Backgrounds of ICU concepts 800 BC: Prophet Elisa- mouth to mouth… 460-70 BC: Hipocrates- 1st Endo-tracheal Intubation…(Treatise on air)… 1550: Paracelsus used “Fire Bellows”, 1 st concept of mechanical ventilation. 1774: John Fothergill- mouth to mouth…. 1774: Dr. William Haves establish “Royal Humane Society” contributed much…
    22. 22. Historical Backgrounds of ICU concepts (Cont…) High pressure-tension pneumothorax… 1837: manual compression of chest… 1864: Dr. Alfred Jones devised “tank Ventilation” known as “Iron lung”. 1889: Alexander Graham Bell devised a vacuum jacket…… 1929: Philip Drinker devised electrically powered tank ventilator, “iron lung”…
    23. 23. Historical Backgrounds of ICU concepts (Cont…) Later developed cuirass All these (tank & cuirass) were negative pressure ventilators 1st recorded concepts of ICU are paralytic poliomyelitis epidemics in ……. 1948: Los Angels 1952: Scandinavia
    24. 24. Historical Backgrounds of ICU concepts (Cont…) 1952: Denmark (severe epidemics)- Ambu by medical students plus tank and cuirass. All were managed by negative pressure ventilations…. Lassen and Ibsen: basic principle of IPPV with modern ventilation (volume, pressure, humidification, oxygen and physiotherapy) 1955: Stockholm and New England epidemics-IPPV….. 1960: IPPV, its superiority and CVS effect.
    25. 25. Mechanical Ventilation (1) • Use of a machine to take over active breathing for a patient • Used for patients who are unable to sustain the level of ventilation necessary to maintain the gas exchange functions - oxygenation and carbon dioxide elimination
    26. 26. Ventilator in RpMCH ICU
    27. 27. Mechanical Ventilation (2) Goals: • Increase efficiency of breathing • Increase oxygenation • Improve ventilation/perfusion relationship • Decrease work of breathing Indications: A. Established acute respiratory failure B. Incipient respiratory failure C. Low output states D. Purposeful hyperventilation
    28. 28. Mechanical Ventilation (Indications) A) Established Acute Respiratory Failure  Primary ventilatory failure – Poisonings which depress the CNS – CNS and neuromuscular disorders ( poliomyelitis, infective polyneuritis, myasthenia) – Snake bites – Severe tetanus  Hypoventilating comatose patients  Acute pulmonary disorders e.g. fulminant pneumonia, acute lung injury (ARDS)  Fulminant pulmonary oedema  Major or massive pulmonary embolism  Major or massive atelectasis  Patients with COPD in acute crisis, unresponsive to conventional therapy  Patients with acute severe asthma , unresponsive to conventional therapy
    29. 29. Mechanical Ventilation (Indications) B) Incipient Respiratory Failure  Obese patients who have undergone upper abdominal surgery, or poor risk surgical patients  Respiratory muscle fatigue in critical illnesses  Patients with excessive ventilatory demands  Patients with acute fulminant parenchymal lung disease with rapidly progressive impairment of pulmonary function and reserve C) Low output states  Shock of any etiology D) Purposeful hyperventilation  To decrease intracranial tension in patients with head injury  To reduce cerebral edema after CPR or massive CVA
    30. 30. Commonly used modes of mechanical ventilation • • • • • • • • Controlled mandatory ventilation (CMV) Assist control ventilation (ACV) Synchronized intermittent mandatory ventilation (SIMV) Pressure support ventilation (PSV) Positive end expiratory pressure (PEEP) Continuous positive airway pressure (CPAP) Bilevel positive airway pressure (BIPAP) Intermittent mandatory ventilation (IMV) Pressure control ventilation (PCV)
    31. 31. Monitoring Mechanics Pressure, flow, and volume Time‐ based graphics (waveforms) – Pressure – Flow – Volume Derived measures – Compliance – Resistance Loops – Pressure volume – Flow volume
    32. 32. analgesia Sedation Muscle relaxation Nutrition Care of a patient on respiratory support Preventing complications Chest infections Venous thrombosis Pulmonary embolism GI bleed Care of vascular lines and tubes Care of lungs Care of unconscious patient Psychological care
    33. 33. Pulmonary Pulmonary barotrauma Chest infection Venous thrombosis Pulmonary embolism Lung fibrosis (late) Alveolar hyperventilation Atelactasis Gastrointestinal Pneumoperitoneum Decreased GI motility Gastrointestinal haemorrhage Complications of mechanical ventilation Cardivascular Decreased cardiac output Dysrhythmias Pulmonary artery catheter complications Others Bacteremia Multiorgan failure Psychological consequences Endocrine dysfunction Pressure sores Nutritional Malnutrition Excess CO2 production Renal Fluid retention Renal failure
    34. 34. Weaning • Process of withdrawal of mechanical ventilatory support that transfers the work of breathing from ventilator to the patient • This period may take many forms ranging from abrupt to gradual withdrawal from ventilatory support • The aim of ventilatory support is to unload the patient’s respiratory pump, while weaning is the process of reloading the respiratory pump
    35. 35. Increased cost Increased risk of VAP Decreases the availability of ICU beds Why Wean early ??? Increased hospital length of stay Increased ICU length of stay Increased morbidity & mortality Can adversely affect the patient outcome
    36. 36. Weaning Criteria Clinical Criteria • Adequate cough • Absence of excessive tracheobronchial secretions • Resolution of the disease acute phase for which the patient was intubated Objective Criteria • Ventilatory criteria • Oxygenation criteria • Pulmonary reserve • Pulmonary measurements • Other factors
    37. 37. Basic monitoring requirements for seriously ill patients • • • • • • • Heart rate Blood pressure Respiratory rate Pulse oximetry Hourly urine output Temperature Blood gases
    38. 38. Non-Invasive Monitoring – Clinical variables – BP – ECG – Echocardiography – Esophageal doppler – Gastric tonometry
    39. 39. Invasive Monitoring – Arterial line – Systolic pressure variation – Central venous pressure – Pulmonary artery catheterization – Cardiac output – Mixed venous oxygen
    40. 40. Maintaining Homeostasis to allow time for recovery Continuous or repeated observation + vigilance in order to maintain homeostasis
    41. 41. Standard ICU personnel Crit Care Med 2003; 31(11):2677–2683 • Vary significantly from hospital to hospital • With respect to structure, services provided, personnel and their level of expertise, and organizational characteristics. • Based on economic and political factors • Depend on the population served, the services provided by the hospital and by neighboring hospitals, and the subspecialties of physicians on the hospital’s staff
    42. 42. Standard ICU personnel (cont..) Crit Care Med 2003; 31(11):2677–2683 Large medical centers frequently have multiple ICUs: • Cardiothoracic surgical ICUs, • Trauma ICUs, • Coronary care units, and • Neurologic/ neurosurgical ICUs. • NICUs Small hospitals may have only one intensive care unit designed to care for a large variety of critically ill patients including adult and pediatric populations. (RpMCH???)
    43. 43. ICU personnel in RpMCH No post of Doctors till now….(needs post creation) Inadequate trained nurses….. No organizational (Organogram) settings till now… ……………………
    44. 44. ICU admission Criteria (Adapted from McQuillan et al BMJ 1998;316:1853-8.) • Threatened airway • All respiratory arrests • Respiratory rate ≥40 or ≤8 breaths/min • Oxygen saturation <90% on ≥50% oxygen • All cardiac arrests • Pulse rate <40 or >140 beats/min
    45. 45. ICU admission Criteria (Cont) (Adapted from McQuillan et al BMJ 1998;316:1853-8.) • Systolic blood pressure <90 mm Hg • Sudden fall in level of consciousness (fall in Glasgow coma score >2 points) • Repeated or prolonged seizures • Rising arterial carbon dioxide tension with respiratory acidosis • Any patient giving cause for concern
    46. 46. Multidisciplinary Approach Acute organ failure (Recoverable)- ICU Main disease- concerned to respective department Any additional problem- to be concerned with respective specialty. X-ray technicians, physiotherapists etc are also concerned.
    47. 47. Mortality rate and expectations Rigon et al. Critical Care 2006 10:R5 doi:10.1186/cc3921 Characteristic Overall population Autologous stem cell transplantation Clinically documented lung disease Absence of congestive heart failure Neurological impairment Neutropenia Unknown cause of acute resp failure Acute respiratory distress syndrome Hospital mortality 97/203 (47.8%) 19/29 (65.5%) 17/27 (63.0%) 3/25 (12.0%) 36/52 (61.2%) 41/71 (57.8%) 24/42 (57.1%) 29/40 (72.5%)
    48. 48. Brain death and Medicolegal Aspects • Cardiac death: – Heartbeat and breathing stop • Brain death: – Irreversible cessation of all functions of the entire brain, including the brain stem
    49. 49. Organ donation • Call LifeLink for all deaths – Donor or not in your eyes – Tissue – bone, corneas, heart valves • Mentioning organ donation to family – LifeLink will approach them after declared, but this approach may (will) be changing back to times when the PICU docs talked with the parents • If family asks you about donation – Acknowledge that it is a wonderful gift they are considering – Tell them you will contact LifeLink to have them available for questions – Contact LifeLink ASAP
    50. 50. References 1. 2. Egan’s – Fundamentals of Respiratory Care 9th ed. International Anaesthesiology Clinics – Update on respiratory critical care, vol 37, no 3, 1999. 3. David W Chang, Clinical application of mechanical ventilation 3nd ed 4. Paul L Marino, The ICU Book, 3rd ed. 5. Farokh Erach Udwadia-Principles of Critical Care, 2nd ed. 6. Joseph M Civetta,Critical care, 3rd ed. 7. Keith Sykes,JDYoung – Respiratory Support in Intensive Care BMJ Publishers,2000 8. PKVerma – Mechanical Ventilation and nutrtion in Critically Ill Patients ,1999 9. Curves and loops in mechanical ventilation – Manual by Drager Medical 10. BiPAP - Manual by Drager Medical

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