Icu monitoring

1. JAMIA MILLIAISLAMIA
CENTRE OF PHYSIOTHERAPYAND REHABILITATION SCIENCES
TOPIC - ICU MONITORING
PHYSIOTHERAPY IN CARDIOPULMONARY CONDITIONS
(402)
SUBMITTED TO: DR. JAMALALI MOIZ
SUBMITTED BY: AZIZA NAZNEEN
BPT IV YEAR

2. INTRODUCTION
 In critical care, the monitoring is essential to the daily care of ICU
patients, as the optimization of patient’s hemodynamic,
ventilation, temperature, nutrition, and metabolism is the key to
improve patients’ survival
 Patients are admitted to an intensive care unit (ICU) for intensive
therapy, intensive monitoring or intensive support. They are not
necessarily critically ill, but are at risk of failure of one or more
major organs. Their needs range from observation of vital signs
after major surgery to total support of physiological systems.
 The primary goal of the intensive care unit (ICU) team is the
achievement of stable cardiopulmonary function and optimal
oxygen transport.
 Monitoring implies regular observation and a systematic
response if there is deviation from a specified range. They are
complementary to clinical observation and not a substitute.
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4. NON INVASIVE MONITORING
 Non-invasive monitoring of a variety of parameters is practised in many
areas, especially ICUs and operating theatres.
 These may all parameters be displayed on a single monitor screen.
 Temperature
 Temperature is continuously monitored by means of an oesophageal or
rectal probe. This determines core temperature, which is usually at least
1°C higher than axillary temperature
 Heart rate
 Heart rate is measured from the electrocardiogram (ECG) trace.
 Artefacts are common. Interference (usually from patient movement or a
warming blanket) may confuse the monitor into showing the presence of a
tachycardia or arrhythmia, while small complexes may be interpreted as
asystole. Physiotherapy may also cause movement artefacts.
 Respiratory rate
 Respiratory rate may be measured by making use of the changing
impedance across the chest wall as it moves with respiration. In systems
which offer this parameter, the sensors are built into the ECG leads. 4

5.  Appropriate physiotherapy treatment (e.g. for lobar lung collapse) may
reduce a rapid respiratory rate, but it must be emphasized that an
already tachypnoeic patient should not be allowed to become exhausted
during treatment as he may rapidly decompensate.
 Blood pressure
 Blood pressure is monitored with a pressure cuff around the upper arm.
An oscillometric method is used to measure blood pressure, with
automatic cuff inflation and deflation
 Non-invasive blood pressure monitoring is performed intermittently, but
the interval between readings may be as short as 1 minute.
 Physiotherapy treatment may cause a patient to become hypertensive,
especially if the treatment causes pain or anxiety. The hypotensive
patient may occasionally become more unstable, and here the risks and
benefits of treatment need to be carefully balanced
 Oxygen saturation
 Oxygen saturation (Clark et al 1992) is continuously measured by a
pulse oximeter with a probe on a finger or ear lobe.
 Hypoxaemia has been shown to occur both during and after chest
physiotherapy (Tyler 1982); awareness and careful monitoring are
therefore important. 5

6.  Capnography
 Continuous measurement of patient inhaled and exhaled CO2
 Waveform display more information than the value
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8. INVASIVE MONITORING
 This requires the use of an invasive catheter, which is inserted
into an artery, a central vein, the pulmonary artery or, in some
neurosurgical centres, the extradural space (for intracranial
pressure (ICP) monitoring).
 The catheter is connected to a transducer which is in turn
connected to a pressure monitor
 The monitor displays pressure wave-forms and values on a real-
time basis
 Common invasively monitored parameters include arterial blood
pressure and central venous pressure (CVP). Arterial cannulation
allows continuous monitoring of blood pressure as well as easy
access for blood gas analysis.
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9. CENTRAL VENOUS PRESSURE
MONITORING
 CVP measures the filling pressure of the right ventricular (RV);
it gives an estimate of the intravascular volume status and is
an interplay of the:
 circulating blood volume
 venous tone and
 right ventricular function
 CVP measurement involves placement of a catheter into a
central vein (generally the superior vena cava), usually via the
subclavian or internal jugular vein. The basilic, external
jugular, and femora] veins may also be used
 Normal CVP is approximately 0 to 5 cm H20 and 5 to 10 cm
H20 if measured at the sternal notch and midaxillary line,
respectively.
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10. Equipment
 Sterile gloves
 Sterile gown and mask (optional)
 Sterile prep solution
 Local anesthetic Syringes
 Sterile flush solution
 Suture material (might be included in the kit)
 Dressing material
 Manometer set (this may vary according to whether C.V.P. to be
transduced or not ) [Any piece of open IV tubing can be used]
 500ml of0.9% Sodium Chloride. (500ml Sodium Chloride with 500
units heparin used in transduced circuits only)
 Pressure bag (only used in transduced circuits) [Pressure transducer
- An electronic system with fast response time & gives a more
accurate wave representation]
 Sedatives (if required) 10

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12. WAVEFORM IN CVP
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 It consists of three upwards (a, c, & v waves) and
two downward defections (x and y descents).
1. ‘a’ wave by right atrial contraction and
occurs just after the P wave on the ECG.
2. The ‘c’ wave due to isovolumic ventricular
contraction forcing the tricuspid valve to
bulge upward into the RA
3. The pressure within the RA then decreases
as the tricuspid valve is pulled away from
the atrium during right ventricular ejection,
forming the X descent.
4. The RA continues to fill during late
ventricular systole, forming the V wave
5. The Y descent occurs when the tricuspid
valve opens and blood from the RA empties
rapidly into the RV during early diastole

13. PULMONARY ARTERY AND PULMONARY
CAPILLARY WEDGE PRESSURE
 The introduction of pulmonary artery catheter (PAC) in clinical
medicine is one of the most popular and important advances in
monitoring.
 With a pulmonary artery catheter:-
 pulmonary capillary wedge pressure (PCWP) may be
monitored
 under most circumstances provides an accurate estimate of
the diastolic filling (preload) of the left heart
 cardiac output (CO) may be measured by means of the
thermodilution technique.
 Systemic vascular resistance (SVR), pulmonary vascular
resistance (PVR), oxygen delivery, and oxygen consumption
may also be calculated.
 The pulmonary artery catheter is inserted via a central vein
through the right side of the heart into the pulmonary artery.
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15. INTRACRANIAL PRESSURE
MONITORING
 Intracranial pressure monitoring may be performed in patients
with head injuries, brain surgery, intracranial and
subarachnoid haemorrhage, and cerebral oedema from other
causes.
 The importance of ICP measurement is that it provides an
estimate of cerebral perfusion pressure (cerebral perfusion
pressure = mean arterial pressure — ICP) which in turn
relates to cerebral blood flow
 Raised ICP causes reduced CBF which leads to tissue
hypoxia and acidosis, raised PCO2 cerebral vasodilatation,
and oedema, all of which cause a further rise in ICP.
 ICP may be measured by means of an extradural or
subarachnoid bolt, an intraventicular catheter (inserted
through the skull ino the lateral ventricle), or an epidural
catheter. The former methods are the most widely used
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17. REFERENCES
1. Dean, E & Frownfelter, D. Cardiopulmonary physical
therapy; (3rd edition)
2. Hough, A. physiotherapy in respiratory care;(3rd edition)
3. Pryor, J.A & Webber, B. A Physiotherapy for respiratory and
cardiac problems; (2nd edition)
4. K. Bendjelid and J. A. Romand, “Fluid responsiveness in
mechanically ventilated patients: a review of indices used in
intensive care,” Intensive Care Medicine
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