PROF. Premkumar. k

1. ICU
PK -2019

2. Intensive care unit (ICU)
Also known as an
• intensive therapy unit
• intensive treatment unit (ITU)
• critical care unit (CCU)
• Icu is a special department of a hospital or
health care facility that provides intensive
treatment medicine.

3. • Patients in ICU with severe and life
threatening illnesses and injuries, which
require constant, close monitoring and support
from specialist equipment and medications in
order to ensure normal bodily functions.

4. ICU UNIT

5. ICU staffs
• Highly trained doctors and nurses who
specialize in caring for critically ill patients
Common conditions that are treated within
ICUs include ARDS , trauma,multiple organ
failure and sepsis

6. Concept & Setup
ICU should be in close relationship to
operation theater &recovery room which allow
easily transport of the critically ill patients from
the ICU to the theatre and vice versa. This is
especially important for the surgical icu or
post operative cases in some reason it is not
possible then the hospital should ensure rapid
vertical transport through elevators or door and
corridor

7. • Ideal ICU allows free movements for
patients, staffs & equipments and possible
new construction unit . rectangular design unit
minimum 350-500 sq . feet / bed
• Eg-semicircular plan & vertical plan icu

8. • ICU should have close relationship with OT&
recovery room. Relationship causality
emergency ward , laboratory , radiology cum
imaginary and physiotherapy department .
 Medical icu has a high proportion of patient
with IHD patients and close relation with
cardiac catheter.

9. • Due to progression of healthcare system
multiple icu departments available like
neonatal ICU , PICU, Critical illness unit,
coronary care unit adjacent cardiac catheter lab
and cardiovascular surgery unit , similarly a
neurological ICU should adjacent to the
neurosurgery theatre neurology ward & Dept

10. Types of ICU
• 2 channel monitoring ( city / dist)
• tertiary level ( teaching or super specialty with
experienced physician ,surgeon , medical staffs
& 4 physiological parameters

11. Types of ICU
• Neonatal intensive care unit (NICU)
• Pediatric intensive care unit (PICU)
• Coronary care unit CCU)
• Psychiatric intensive care unit (PICU)
• Neurological intensive care unit (Neuro ICU).
• Trauma intensive care unit (Trauma ICU).
• Post-anesthesia care unit (PACU): High dependency
unit (HDU)/ step down unit or progressive care unit )
• Surgical Intensive Care Unit (SICU)
• Mobile Intensive Care Unit (MICU)

12. ICU DESIGN
Three areas are important for the activity
1.The patient area
2. Staff area- mainly nurses (1:1) and doctors
3. The support area
Requirements- 4 basic
1.Direct observation of the patients by nurse and medical
staff
2.Availability of physiological monitoring
3.Provision efficient to use of routine and emergency
diagnostic procedures and therapeutic interventions
4.Recording and maintains of patient information

13. Types monitoring devices
• Patient monitoring devices
• Life support and emergency resuscitation
devices
• Diagnostic devices

14. PATIENT MONITORING
• Arterial line
• Bed side monitor
• Blood pressure device(sphygmomanometer)
• Electrocardiograph(ECG or EKG machine)
• Electroencephalograph(EEG machine)
• Intracranial pressure monitor
• Pulse Oximeter
• Glucometer

15. LIFE SUPPORT AND EMERGENCY
RESUSCITATION DEVICES
• Mechanical Ventilator
• Laryngoscope
• Airway
• Infusion pump
• Crash cart(Resuscitation cart)
• Intra aortic ballon pump
• Continuous positive air pressure machine (CPAP)
• Defibrillator

16. DIAGNOSTIC EQUIPMENT
• Mobile x-ray units & portable clinical
laboratory devices
• Bronchoscope ,Colonoscope ,Endoscope
,Gastroscope
OTHER ICU EQUIPMENT- Disposable Urinary
catheter& drainage collector, Suction
catheter,Nasogastric (NG) tube ,IV line or
catheter ,Feeding tube, Breathing tube( ETT)

17. Routine monitoring
New symptom, sign, or a finding
1.Behaviors of the patient
1.Anxiety, fear -Response to new environment /
ventilator
2.Restlessness, agitation -↓Pao2: Check Spo2,
patient on ventilator system
Pain : check pain medication- use sedatives
3.Confusion, disorientation- decreased
responsiveness, no response to stimuli
Use GCS scale to determine patient’s level of
alertness

18. Routine monitoring..
• ↓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
4.Twitching / convulsions / tetany- ↓ed serum
levels of anticonvulsants in a patient with known
convulsive disorder ↓PaCo2 with rising pH.
5.Breathlessness-Anxiety, ↓ PaO2, ↓ed ventilation,
pneumothorax.

19. Routine monitoring…
• Altered chest wall movements - Paradoxical
movement / flail chest- Inward movement of
thorax during inspiration
• Lower cervical cord transaction Asynchronous
movement of the thorax and abdomen
• Splinting after abdominal surgery, COPD,
diaphragmatic paralysis, respiratory muscle
fatigue with impending respiratory failure

20. Inspection
Unilateral decrease in chest wall expansion –
• Intubation of right mainstem bronchus ,Splinting
secondary to pain, air, blood, or fluid in the pleural
cavity, Atelectasis, Consolidation, Obstruction of
major bronchus
• Asynchrony with the ventilator – Anxiety, pain
,airway obstruction at the level of ETT

21. • Migration of tubes –above vocal cord / main
bronchus
• 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

22. 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.

23. Vital signs
1. Blood pressure – monitor every 1-4 hours
Hypotension
• Decreased intravascular volume
• High external or internal PEEP
• Cardiac failure and Drugs – sedatives and
vasodilators
• Check drainage system
• Look for inadvertent discontinuation of inotropes
or leak from IV site

24. • 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.

25. Hypertension
• Anxiety
• Inadequate sedation,
• ↑ed PaCO2, other causes of sympathetic
stimulation,
• Drugs – vasopressors,
• 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.

26. 2. Heart rate and rhythm (arrhythmias,
tachycardia, bradycardia) – monitor hourly
Anxiety, inadequate sedation, drugs,
↓PaO2,↓PaCO2, ↑PaCO2 (check SpO2, ABG,
patient-ventilator system), ↓ed intravascular
volume.
 Evaluate other haemodynamic parameters for
the adequacy of perfusion

27. 3.Urinary output – monitor hourly
• ↓ed urine output : inadequate perfusion of
kidneys, low intravascular volume, and onset
of acute renal failure.
• ↑ed urine output :(>50 ml/hr) in the absence of
diuretics or diuretic phase of renal failure
(overhydration) (Normal urine output : 0.5-
1.0mL/kg/hr in adults, 1mL /kg/hr in children).

28. 4.Temperature: monitor every 8 hours
• Fever – overheated humidifier, atelectasis,
infection, ↑ed metabolic rate caused by ↑ed
inspiratory effort
• Geriatric patients have a lower body
temperature and are more easily influenced by
environmental temperature.

29. • Hypothermia : ↓ed environmental temperature
• Rectal temperature (related more closely to
core body temp.) is approximately 0.50 C
higher than the oral temperature

30. 5.Respiratory rate : monitor every 1-4
hours
• RR may be influenced by altered ventilator
settings
• Changes in metabolic needs (anxiety, stress,
infection, infection, heart failure, pulmonary
edema,)

31. • ↓ed PaO2
• ↑ed PaCO2
• Drugs (sedatives, narcotics, anesthetic agents)
• ↑ed intracranial pressure

32. Weight gain, peripheral edema :monitor
daily
• Heart failure, hypoproteinemia ,venous or
lymphatic obstruction, sepsis, shock, trauma
etc
• 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”.

33. 6.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.
Longer period indicates vasoconstriction/
reduced cardiac output
Oxygen saturation with pulse oximeter – monitor
continuously
End tidal CO2
Central venous pressure.

34. 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)
Observe the colour of secretions

35. Breath sounds-monitor every 1-4 hours
• Unilateral ↓ed breath sounds: blocked ETT,
ETT migration into a mainstem bronchus, air,
blood, or other fluid in the pleural space,
pneumonia

36. • ↓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)

37. • ↓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)

38. • Presence of wheeze : asthma, congestive heart
failure, bronchitis, high flow rate
• Inspiratory and expiratory crackles present:
bronchitis, respiratory infections, and secretions
• Subcutaneous emphysema-monitor every 2-4
hours Mechanical ventilation of a patient with
fresh tracheostomy, laceration of lung or chest
wall secondary to trauma or surgery, tension
pneumothorax

39. • Air leak via chest tube – monitor every 1-4
hours
• New pneumothorax : Obtain and evaluate X-
ray chest and ABG
• Broncho-pleural fistulae : change ventilatory
settings if required

40. Skin temperature
• Inadequate perfusion to the extremity, core
temperature of body and environmental
temperature.
• A difference of <2* C indicates hypoperfusion
and a difference of < 5* C indicates a life-
threatening situation resulting from reduced
perfusion.
• Cold and clammy skin occurs as a result of
sympathetic stimulation, and is a compensatory
mechanism for a decrease in cardiac output-
indicates impending shock

41. Gastric distension - monitor every 1-4
hours
• Mal positioning of ETT, Air swallowing,
Excessive inspiratory effort by the patient,
Nutritional intolerance,Blocked nasogastric
tube

42. Lab. investigations
• Arterial blood gas (ABG) analysis
• Serum electrolytes -Daily or twice weekly
• Blood urea, serum creatinine- Twice a week or
daily
• Liver function tests- Weekly or twice a week
• X-ray chest- Daily
• Cultures from various sites