critical care

1. 1Prof. Dr. RS Mehta, BPKIHS

2. Introduction
 The intensive care unit (ICU) is the hospital facility within
which the highest level of continuous patient care and
treatment care are provided.
 ICU cases include a variety of severe cases due to
major surgical interventions, trauma, hemodynamic
instability, sepsis and so on.
 All of these factors can easily lead to MODS (multiple
organ dysfunction syndromes).
2Prof. Dr. RS Mehta, BPKIHS

3. Introduction …
 Multiple organ dysfunction syndromes are the leading
cause of mortality in critically ill patients and is
responsible for a large amount of healthcare expenditure.
 Since the probability of death is directly correlated to the
number of failing organs beyond the kidney and the
degree of physiological derangement, a clinically sensible
approach is to broaden the spectrum of physiological
endpoints targeted by extracorporeal therapy.
3Prof. Dr. RS Mehta, BPKIHS

4. Introduction …
 Blood is the vital element that regulates all body
systems from cellular to organ level.
 A multiple organ support therapy is a logical and
should be the goal of extracorporeal blood purification
in the intensive care unit.
4Prof. Dr. RS Mehta, BPKIHS

5. Indication of ICU admission
 Patients requiring, likely require,
advanced respiratory support alone.
 The patient requiring support of two
or more organ systems.
 Patients with co-morbidity who
require support for an acute
reversible failure of another organ
system
5Prof. Dr. RS Mehta, BPKIHS

6. 6Prof. Dr. RS Mehta, BPKIHS

7. Clinical feature of patient requiring organ
system support
 Confusion
 Decrease GCS
 Shortness of breath
 Rapid or irregular heart beat
 Rapid, shallow breathing
7Prof. Dr. RS Mehta, BPKIHS

8. Clinical feature of patient requiring organ system support…
 Grunting sounds
 Flaring of the nostrils
 Decrease urine output=
(<400ml/24 hours oliguria or 50ml/12hours anuria)
8Prof. Dr. RS Mehta, BPKIHS

9. Investigations
 Echocardiography-two-dimensional with Doppler flow studies may
show ventricular hypertrophy, dilation of chambers, and abnormal
wall motion.
 ECG (resting and exercise) may show ventricular hypertrophy and
ischemia.
 Chest X-ray may show cardiomegaly, pleural effusion, and vascular
congestion.
 Cardiac catheterization to rule out CAD
 ABG studies may show hypoxemia due to pulmonary vascular
congestion.
 Liver function studies may be altered because of hepatic congestion.
9Prof. Dr. RS Mehta, BPKIHS

10. Investigations…
 Renal function test may be altered because of renal congestion.
 Imaging
 Chest X-ray may show cardiomegaly, pleural effusion, and
vascular congestion.
 Computed tomography (CT) scan is a structural imaging study
that uses a computer-based X-ray to provide a cross-sectional image
of the brain.
 MRI is a noninvasive structural imaging procedure that uses
powerful magnetic field and radio frequency waves to create an
image of brain and others organ.
 Positron-emission tomography (PET): A computer-based
functional imaging technique that permits study of the brain's
metabolism, blood flow, and chemical processes.
10Prof. Dr. RS Mehta, BPKIHS

11. Objective of multiple organ support therapy
 Protect the organs before organ failure
 Restrict tissue hypoxia
 Reduce an excessive inflammatory response
 Protect against oxidant damage
 if multiple organ failure is already established, the
cells might need to be rested.
11Prof. Dr. RS Mehta, BPKIHS

12. Categories of organ system support therapy
 Respiratory support therapy
 Circulatory support therapy
 Renal support therapy
 Hemodynamic monitoring or support therapy
 Neurological monitoring or support
12Prof. Dr. RS Mehta, BPKIHS

13. Respiratory support therapy
a. Advanced respiratory support
therapy
b. Basic respiratory support
therapy
13Prof. Dr. RS Mehta, BPKIHS

14. Advanced respiratory support
 Immediate tracheal intubation
and mechanical ventilation
support (excluding mask
continuous positive airway
pressure, CPAP) or non-
invasive ventilation.
14Prof. Dr. RS Mehta, BPKIHS

15. Indication
 Upper and Lower airway obstruction as a result of
blockage caused by blood or pus or bronchospasm and
edema.
 Neuromuscular disorders as in Myasthenia gravis,
Poliomyelitis, Guillain-Barré syndrome, Snake bite and
inadequate reversal of anesthesia.
 Lung diseases which prevent proper exchange of O2 and
CO2 as in chest injuries pneumothorax, lung infections,
COPD, Adult Respiratory Diseases Syndrome (ARDS).
15Prof. Dr. RS Mehta, BPKIHS

16. Indication …
 Post-operative cardiac surgery, any other surgery,
shock & trauma.
 Respiratory arrest
 Acute respiratory acidosis with partial pressure of
carbon dioxide (pCO2) > 50 mmHg (normal : 35- 45)
and pH < 7.25.
 Hypoxemia.
16Prof. Dr. RS Mehta, BPKIHS

17. Basic respiratory support
 Assisting in coughing, deep breathing and alveolar
recruitment techniques ( e.g., CPAP)
 Chest percussion
 positioning (e.g. fowlers position)
 Bronchodilators
 Suctioning
17Prof. Dr. RS Mehta, BPKIHS

18. Basic respiratory support…
 Tracheostomy care.
 Physiotherapy to clear secretions at least 2 hourly
 Use of supplemental oxygen (restricted to certain
situations like COPD)
 Use of an incentive spirometer to increase inhaled
lung volume and eliminate mucous and saliva
18Prof. Dr. RS Mehta, BPKIHS

19. Basic respiratory support…
 Inspiratory muscle training to help strengthen
diaphragm muscles
 Nebulization
 Feeding modifications to reduce aspiration risks
19Prof. Dr. RS Mehta, BPKIHS

20. Indications
 The possibility of progressive deterioration to the
point of needing advanced respiratory support.
 Patients in whom the tracheal tube has been
removed recently after prolonged period of
intubation and mechanical ventilation.
 The need for mask CPAP or non-invasive
ventilation.
 Patients whose trachea is intubated to protect the
airway but who do not need mechanical ventilation.
 Bed ridden patients or prolonged immobility.
20Prof. Dr. RS Mehta, BPKIHS

21. Nursing consideration
 Assess respiratory rate and depth; Inspect thorax for
symmetry of movement.
 Assess the patient for oxygenation such as oxygen saturation,
signs and symptoms of hypoxia (tachypnea, nail beds, ABG
analysis, auscultation for air entry).
 Observe for tube misplacement. Prevent accidental
extubation by taping tube securely, checking q.2h.
 Maintain ventilator settings as ordered.
 Elevate head of bed 60-90 degrees.
21Prof. Dr. RS Mehta, BPKIHS

22. Circulatory support therapy
 Mechanical circulatory support
Use of Intra-aortic balloon pump
with a ventricular assist device
(VAD).
 Medical therapy including use of
angiotensin converting enzyme
inhibitors, beta blockers, and
aldosterone antagonists.
22Prof. Dr. RS Mehta, BPKIHS

23. Intra-aortic balloon pump A ventricular assist device
23Prof. Dr. RS Mehta, BPKIHS

24. Indications
 Cardiogenic shock resulting from acute myocardial
infarction (AMI).
 Postsurgical myocardial dysfunction
 Acute cardiac failure from myocarditis
 Decompensated chronic heart failure
 Dilated cardiomayopathy
24Prof. Dr. RS Mehta, BPKIHS

25. Nursing consideration
 The nurse plays a critical role in caring for the patient
receiving intra-aortic balloon counterpulsation .
 The nurse makes ongoing timing adjustments of the balloon
pump to maximize its effectiveness by synchronizing it with
the cardiac cycle.
 The patient is at great risk for circulatory compromise to the
leg on the side where the catheter for the balloon has been
placed; therefore, the nurse must frequently check the
neurovascular status of the lower extremities.
 Auscultate heart sounds frequently and monitor cardiac
rhythm.
25Prof. Dr. RS Mehta, BPKIHS

26. Renal support therapy
 Acute renal replacement therapy: is a
term used to encompass life-
supporting treatments
for renal failure. it includes:
hemodialysis, peritoneal dialysis.
 Hemodialysis: Hemodialysis is a
process of cleansing the blood of
accumulated waste products. In
haemodialysis the blood flows through
a dialysis machine that filters away the
waste products.
26Prof. Dr. RS Mehta, BPKIHS

27. Renal support therapy…
 Peritoneal dialysis: Peritoneal
dialysis involves the repeated cycles
of instilling dialysate into the
peritoneal cavity , allowing time for
substance exchange , and then
removing the dialysate. PD is
typically used for client with severe
cardiovascular disease
27Prof. Dr. RS Mehta, BPKIHS

28. Indication of dialysis
 Oliguria (urine output <200 mL/12 h)
 Anuria/extreme oliguria (urine output <50 mL/12 h)
 Hyperkalemia (K >6.5 mEq/L)
 Severe acidemia (pH <7.1)
 Azotemia (urea >30 mg/dL)
 Pulmonary edema
28Prof. Dr. RS Mehta, BPKIHS

29. Nursing consideration
 Assess for bleeding at the access site or elsewhere. Use standard
precautions at all times. Renal failure and heparinization during dialysis
increase the risk for bleeding.
 Assess for dialysis disequilibrium syndrome, with headache, nausea and
vomiting, altered level of consciousness; and hypertension.
 Assess for other adverse responses to dialysis, such as dehydration,
nausea and vomiting, muscle cramps, or seizure activity.
 Assess and document vital signs, weight, and vascular access site
condition.
 Monitor BUN, serum creatinine, serum electrolyte, and Hematocrit
levels between dialysis treatments.
29Prof. Dr. RS Mehta, BPKIHS

30. Liver support therapy
 Liver failure is defined as an insufficiency of any facet of liver
function to a degree that this insufficiency leads to secondary
organ failures and creates a life threatening situation if
untreated.
 Artificial extracorporeal liver support is a term that is used
to describe measures that are used to carry out liver function
and are outside of the body. The Molecular Adsorbent
Recirculation System (MARS) is an example of artificial
extracorporeal liver support.
 The ultimate goal of extracorporeal liver support is to prolong
the survival time of patients with liver failure by preventing
progression of secondary organ failure.
30Prof. Dr. RS Mehta, BPKIHS

31. The Molecular Adsorbent Recirculation System (MARS)
 The MARS system combines the
efficacy of sorbents to remove
albumin-bound toxins with the
high selectivity of highly
biocompatible dialysis
membranes.
 In this way, common dialysis or
CRRT machines can be expanded
into a modern system for liver
support therapy.
31Prof. Dr. RS Mehta, BPKIHS

32. Nursing consideration
During MARS therapy, there is
potentially chance to occur bleeding
complications and mortality so observe
feature of bleeding.
Monitor BUN, serum creatinine, serum
electrolyte, ammonia, albumin, AST,
ALT between dialysis treatments.
32Prof. Dr. RS Mehta, BPKIHS

33. Hemodynamic support
Hemodynamics are the forces which
circulate blood through the body.
 Specifically, hemodynamics is the term
used to describe the intravascular
pressure and flow that occurs when the
heart muscle contracts and pumps blood
throughout the body.
33Prof. Dr. RS Mehta, BPKIHS

34. Hemodynamic support…
 Hemodynamic monitoring refers to
measurement of pressure, flow and
oxygenation of blood within the
cardiovascular system. Hemodynamic
support includes:
Fluid resuscitation/Blood transfusion
Use of vasoactive drugs like nitroglycerine,
amlodipine, nitric oxide, hydralazine.
34Prof. Dr. RS Mehta, BPKIHS

35. Indications
 Decreased urine output from dehydration
 Hemorrhage
 G.I bleed
 Burns or surgery
 All types of shock; cardiogenic shock, neurogenic
shock or anaphylactic shock.
Any deficits or loss of cardiac function: such as
myocardial infarction, congestive heart
failure, cardiomyopathy
35Prof. Dr. RS Mehta, BPKIHS

36. Nursing consideration
 Administer fluid as prescription.
 Assess the sign of cardiac overload like dyspnea,
increase CVP, edema, weight gain, crackles (rales) and
bounding pulse etc.
 Measure intake and output.
36Prof. Dr. RS Mehta, BPKIHS

37. Neurological monitoring or support
 Central venous system depression sufficient to compromise
the airway and impair protective reflexes.
 Invasive neurological monitoring:
 A common complication of many serious neurologic
conditions is an elevation of the pressure within the skull, the
intracranial pressure or ICP.
 In adults, the average ICP ranges from <10-15 mm Hg . 20 mm
Hg is considered to be the maximal upper limit of desirable
ICP and pressures exceeding 40 mm Hg are considered
extremely elevated.
37Prof. Dr. RS Mehta, BPKIHS

38. Neurological monitoring or support
 Whatever the underlying cause an increase in
intracranial pressure is extremely dangerous.
 The type of monitor used is dependent on a number
of clinical factors, not the least of which is the
neurologic disease causing the pressure increase.
 The following devices commonly used to
monitor and treat intracranial pressure:
Intraventricular catheter
38Prof. Dr. RS Mehta, BPKIHS

39. Intraventricular catheter
39Prof. Dr. RS Mehta, BPKIHS

40. Nursing consideration
 Proper positioning helps to reduce ICP. The head is
kept in a neutral (midline) position, maintained with
the use of a cervical collar if necessary, to promote
venous drainage.
 Elevation of the head is maintained at 30 degrees to aid
in venous drainage unless otherwise prescribed.
 Assess the level of consciousness( GCS).
 Pupillary reaction.
 Maintain aseptic technique while measuring ICP.
40Prof. Dr. RS Mehta, BPKIHS

41. 41Prof. Dr. RS Mehta, BPKIHS