critical care- for the purpose of reading and update the knowledge this content would be helpful

1. COURSE I - INTRODUCTION TO CRITICAL CARE PRINCIPLES AND PROCEDURES
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STRUCTURE
Course 1: Introduction to critical care principles and procedures
Course 2: Critical care competencies - I
Course 3: Critical care competencies - II
PROGRAME COORDINATORS
Coordinators from University of Hyderabad:
1) Dr. M. Vara Lakshmi, School of Medical Sciences, UoH; Dr. Varalakshmi M,
Assistant Professor, School of Medical Sciences, UoH
2) Prof. Prakash Babu P, Dean - School of Medical Sciences, UoH
Coordinators from AMSL:
1) Dr. Srinivasa Rao Pulijala, CEO, AMSL
2) Ms. Swaroopa Amarapuri, Manager, Nursing Education, AMSL
COURSE CONTRIBUTORS
1) Dr. M. Vara Lakshmi, School of Medical Sciences, UoH; Dr. Varalakshmi M,
Assistant Professor, School of Medical Sciences, UoH
2) Ms. Swaroopa Amarapuri, Manager, Nursing Education, AMSL
3) Ms. NagaLakshmi, Nurse Educator, Apollo MedSkills
TECHNICAL SUPPORT
1) Ms. P. Swarna Latha, Nurse Educator, Apollo MedSkills
2) Ms. P. Swarna Lahari, Nurse Educator, Apollo MedSkills
3) Ms. Mallepogu Keerthi, Nurse Educator, Apollo MedSkills
4) Mr. Ganapala Manoj, Nurse Educator, Apollo MedSkills
5) Ms. Dodda Swathi, Nurse Educator, Apollo MedSkills
6) Ms. Termati Sampurna, Nurse Educator, Apollo MedSkills
7) Ms. Saraswathi, Nurse Educator, Apollo MedSkills
8) Ms. Padma Latha, Nurse Educator, Apollo MedSkills
9) Ms. Deborah, Nurse Educator, Apollo MedSkills
10) Ms. Varunsri, Nurse Educator, Apollo MedSkills

2. COURSE I - INTRODUCTION TO CRITICAL CARE PRINCIPLES AND PROCEDURES
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BLOCK 1: FUNDAMENTALS IN CRITICAL CARE
Unit 1: Concepts of Critical Care Units
- Brief History of Critical Care
- Aims, Purposes, Indications
- Trends and Challenges of Critical Care

3. COURSE I - INTRODUCTION TO CRITICAL CARE PRINCIPLES AND PROCEDURES
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UNIT 1: CONCEPTS OF CRITICAL CARE
STRUCTURE
1.0 Brief History of Critical Care
1.1 Aims, Purposes, Indications
1.2 Trends and Challenges of Critical Care
LEARNING OBJECTIVES
At the end of unit, the learner will be able
to:
Enumerate brief history of Critical care
List out the aims & purposes
Enlist the indications
Discuss the trends and challenges
1.0BRIEF HISTORY OF CRITICAL CARE
Critical care is a term used to describe as the
care of patients who are extremely ill and
whose clinical condition is unstable or
potentially unstable. Critical care evolved
from an historical recognition that the
needs of patients with acute, life-
threatening illness or injury could be better
treated if they were grouped into specific
areas of the hospital. Following the Crimean
War (1854-1856), Florence Nightingale
described the advantages of specialized
areas for the recovery of postoperative
patients. Intensive care began in the United
States in 1920’s, when Dr. W.E. Dandy
established the first 3-bed neurosurgical
ICU at Johns Hopkins Hospital in Baltimore.
In 1927, the first premature infant care
center was established in Chicago  During
World War II, “shock wards” were created
to resuscitate wounded soldiers. As a result
of the nursing shortage that followed World
War II, postoperative patients were
grouped in “recovery rooms” to ensure
attentive care  The benefits recognized led
to establishment of recovery rooms in
nearly every U.S. hospital by 1960.
In 1947-1948, the polio epidemic raged
through Europe and the United States,
resulting in a breakthrough in the treatment
of patients dying from respiratory paralysis.
In Denmark, manual ventilation was
accomplished through a tube placed in the
trachea of polio patients. Patients with
respiratory paralysis and/or suffering from
acute circulatory failure required intensive
care. With the efficacy of centralized care of
the critically ill proven, respiratory ICU’s
were developed in many hospitals.
During the 1950s, the development of
mechanical ventilation led to the
organization of respiratory intensive care
units (ICUs) in many European and
American hospitals. The care and
monitoring of mechanically ventilated
patients proved to be more efficient when
patients were grouped in a single location.
General ICUs for very sick patients,
including postoperative patients, were
developed for the similar reasons.  In 1958,
approximately 25 percent of community
hospitals with more than 300 beds reported

4. COURSE I - INTRODUCTION TO CRITICAL CARE PRINCIPLES AND PROCEDURES
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having an ICU. By the late 1960s, most
United States hospitals had at least one ICU.
During the 1960’s “critical care” developed
as a specialty in response to improve
patient outcome with ICU care,
advancements in postoperative
resuscitation and monitoring, surgeon’s
willingness to perform more ambitious
surgical procedures. By 1970, most U.S.
hospitals had at least one ICU.
1970, 29 physicians with a major interest in
the care of the critically ill and injured met
in Los Angeles, California to discuss the
formation of an organization committed to
meeting the needs of critical care patients:
the Society of Critical Care Medicine
(SCCM). In 1986, the American Board of
Medical Specialties approved a certification
of special competence in critical care for the
four primary boards: anesthesiology,
internal medicine, pediatrics, and surgery.
Between 1990 and the present, critical care
significantly reduced in-hospital time as
well as costs incurred by patients with
diseases such as cerebrovascular
insufficiency and lung tumors. The
development of new and complicated
surgical procedures, such as
transplantation of the liver, lung, small
intestine, and pancreas, created a new and
important role for critical care following
transplantation.
Widespread utilization of non-invasive
patient monitoring has further reduced the
cost and medical/nursing complications
associated with care of critically ill and
injured patients. Widespread utilization of
pharmacologic therapy for critical care
patients with specific organ system failure
reduced time spent in both critical care
units and in the health care facility. In 1997,
more than 5,000 ICUs were operational in
intensive care units across the United
States.
Critical care practices in India have evolved
significantly over the past decade. As in
most other developing nations, critical care
medicine as a specialty has developed very
slowly and only recently in India. The
coronary care units were developed in the
early to mid-1970s. Perhaps the main
pioneer of the field of critical care in India
was Farokh E Udwadia, a brilliant physician
with international training in pulmonology.
In the mid1970s, Udwadia developed the
first respiratory care units in the country in
two hospitals in Mumbai — a community
hospital and a private one.  The most major
achievement of these units was not only to
bring down the mortality of tetanus, but
also to open the eyes of society to the need
for critical care services. These few
enthusiastic, trained consultants came
together in 1992 to discuss critical care on a
common platform, and they formed the
national Indian Society of Critical Care
Medicine (ISCCM).
The society had its teething troubles and
has now established itself very firmly as a
representative body of critical care
consultants in India. The ISCCM has over
2000 members today, and has 16 city
branches. Manpower development of the
specialists has been a major issue. Most of
the current directors have been trained
abroad  The certificate course in critical
care, the first organized training activity in
critical care medicine, was started 4 years
ago by the ISCCM and has been evolving
well. Postdoctoral Fellowship in Critical
Care Medicine conducted by the National
Board of Examinations has recently been

5. COURSE I - INTRODUCTION TO CRITICAL CARE PRINCIPLES AND PROCEDURES
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announced. The training of nurses,
technicians, and therapists has begun in
some isolated foci but has not evolved into a
meaningful training activity.
The evolution of Critical Care Medicine is
traced in relationship to its predecessors,
namely Intensive Care and Intensive
Therapy. The development of incubators for
newborns and life-support devices to
support ventilation and renal function or to
reverse fatal arrhythmias characterized
Intensive Therapy of the early 20th century.
In the most recent 50 years, Critical Care
evolved for comprehensive, largely
electronic monitoring and automated
laboratory measurements to guide
intensive therapy of multi organ failures by
critical care physicians and nurse
specialists, pharmacists, and respiratory
therapists using multiple life-support
methodologies and devices. Critical care in
India is thus at the crossroads of
development. In this 21 1st century, there is
still a long way to go as the critical care field
is full of dynamism, opportunity and
challenges. One hopes that all the efforts
will lead to a humane, scientific and
meaningful service for the multitude of
critically ill patients.
1.1 AIMS, PURPOSES AND INDICATIONS
Critical Care:
Critical care is a term used to describe as the
care of patients who are extremely ill and
whose clinical condition is unstable or
potentially unstable.
Critical Care Unit:
Critical care unit is a specially designed and
equipped facility, staffed by skilled
personnel to provide effective and safe care
for dependent patients with a life
threatening condition.
AIMS OF CRITICAL CARE
 To see that one provides a care such
that patient improves and survives the
acute illness or tides over the acute
exacerbation of the chronic illness.
 To ensure that one provides a care such
that patient improves and survives the
acute illness or tides over the acute
exacerbation of the chronic illness.
 To promote excellence of care of
critically ill patients by specialist nurses
and their professional colleagues.
 To provide an international and
interdisciplinary forum for the
publication, dissemination and
exchange of research findings,
experience and ideas.
 To develop and enhance the knowledge,
skills, attitudes and creative thinking
essential to good critical care nursing
practice.
PURPOSES OF CRITICAL CARE
Delivery of optimal and appropriate
care
Relief of distress
Compassion and support
Dignity
Access to information
Care and support of relatives and care
givers
NEED OF CRITICAL CARE
To Assess life threatening conditions
Initiate appropriate interventions

6. COURSE I - INTRODUCTION TO CRITICAL CARE PRINCIPLES AND PROCEDURES
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Evaluate the outcomes of interventions
Provide education and emotional
support to care givers.
INDICATIONS OF CRITICALLY ILL
PATIENTS
They are grouped by the system of the body.
A) Cardiac system: Acute myocardial
infarction with complications,
cardiogenic shock, complex arrhythmias
requiring close monitoring and
intervention, acute congestive heart
failure with respiratory failure and/or
requiring hemodynamic support,
hypertensive emergencies, unstable
angina, particularly with dysrhythmias,
hemodynamic instability, or persistent
chest pain, cardiac tamponade or
constriction with hemodynamic
instability, dissecting aortic aneurysms
and complete heart block.
B) Pulmonary System: Acute respiratory
failure requiring ventilatory support,
pulmonary emboli with hemodynamic
instability, massive hemoptysis.
C) Neurologic disorder: Intracranial
hemorrhage, meningitis with altered
mental status or respiratory
compromise, central nervous system or
neuromuscular disorders with
deteriorating neurologic or pulmonary
function, status epilepticus and severe
head injured patients.
D) Drug Ingestion and Drug Overdose:
Hemodynamically unstable drug
ingestion, drug ingestion with
significantly altered mental status with
inadequate airway protection, seizures
following drug ingestion.
E) Gastrointestinal Disorders: Life
threatening gastrointestinal bleeding
including hypotension, angina,
continued bleeding, or with comorbid
conditions, hepatic failure and severe
pancreatitis.
F) Endocrine: Diabetic ketoacidosis
complicated by hemodynamic
instability, altered mental status,
respiratory insufficiency, or severe
acidosis, severe hypercalcemia with
altered mental status, requiring
hemodynamic monitoring, hypo or
hypernatremia with seizures, altered
mental status, hypo or hyper
magnesemia with hemodynamic
compromise or dysrhythmias, hypo or
hyperkalemia with dysrhythmias or
muscular weakness and
hypophosphatemia with muscular
weakness.
G) Surgical: Post-operative patients
requiring hemodynamic
monitoring/ventilatory support or
extensive nursing care.
H) Miscellaneous: Septic shock with
hemodynamic instability, hemodynamic
monitoring, environmental injuries
(lightning, near drowning,
hypo/hyperthermia).
1.2 TRENDS AND CHALLENGES OF
CRITICAL CARE
TRENDS
Critical care is one of the most challenging
and important areas of health care. Nurses,

7. COURSE I - INTRODUCTION TO CRITICAL CARE PRINCIPLES AND PROCEDURES
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doctors allied health professionals and
researchers are constantly looking for new
ways to improve patient care, health
professional’s safety and efficiency in
critical care units like the ICU. In the past
two decades. There has been tremendous
growth of intensive care medicine in India.
1. Caring for a Child in Adult ICU
Although not as common in many hospitals,
there are circumstances where a child ends
up in the adult ICU. In these cases, the
nursing staff has to make adjustments from
the protocols they commonly use to
protocols that are better suited for children.
The two specific scenarios up for discussion
are based around a couple of the most
common cases – a 12-year- old head trauma
child and a two-year-old child with
respiratory failure.
2.Manual Hyperinflation
Manual hyperinflation is a useful maneuver
that critical care specialist can apply to
mimic a cough in the patient, which
mobilizes secretions for removal and clears
the airway. However, this technique comes
with potential side effects, and more
research is required to determine the
benefits for critically ill intubated and
mechanically ventilated patients.
3.Using Better Tools in the ICU
In addition to improving techniques,
another growing trend is the use of better
tools in the ICU. New innovative equipment
improves safety for patients and
practitioners, as well as improving the
quality of care patients receive. As the
leading stopcock provider in the US and
Europe, Elcam Medical continues to strive
for better critical care by creating better
tools such as the Marvelous Stopcock.
Research shows that the Marvelous
Stopcock improves patient and worker
safety with its unique design.
4. Standardized Critical Care
Resuscitation and Emergency Airway
Management
Critical care specialist will be a part of
Emergency response team to participate
and perform standardized Critical Care
Resuscitation such as Cardia Pulmonary
Resuscitation, Advanced Cardiac Life
Support (ACLS), Neonatal Advanced Cardiac
Life Support (NALS), Pediatric Advanced
Cardiac Life Support (PALS) and Emergency
Airway Management to avoid ventilation-
related complications.
CHALLENGES
Technological and intellectual
sophistication has dramatically changed our
world forever. Healthcare advancements in
particular have eradicated some diseases
and enabled us to save many lives from
illness and disease that would once have
been futile. Critical care has been a
significant player in the healthcare armoury
for the last 50 years of human existence and
is now consuming a significant proportion
of the healthcare cost in many countries.
Proper management of critically ill patients
requires adequate material, human,
infrastructure and financial resources.

8. COURSE I - INTRODUCTION TO CRITICAL CARE PRINCIPLES AND PROCEDURES
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Worldwide, due to pandemic Covid crisis,
there is a huge problem in health care
services regarding resource allocation such
as insufficient beds, oxygen cylinders and
ventilators, critical care or intensive units,
critical care specialist etc. However, in
Intensive care units (ICUs), this problem is
exacerbated by the fact that patients are
critically ill and require expensive
treatments, life support machines, skilled
personnel and constant monitoring.
Monitoring of ICU patients has high
financial implications, including equipment
and consumable costs, trained staff, their
salaries and the recruitment of specialist
doctors etc.
The following issues and challenges are
seen in CCU’s and ICU’s. The CCU staff
encounters competing demands in caring
for ICU patient and for these patients’ family
members.
1) Inadequate intensive care unit–trained
staff
2) Lack of written policies for managing
ICU patients’ family members
3) Inadequate preparation to provide
information to family members
4) Managing the continued presence of
family members in the ICUSs
5) Family members’ inability to rest
6) Dealing with specific religious practices
7) Competing demands for providing care
to ICU patients and their family
members
8) Not able to protect patients’ rights &
human dignity
9) Informed consent to treatment
10) Working with an
unethical/incompetent/impaired
colleague
11) Limited Intensive care unit beds
12) Shortage of Life saving equipment
13) Shortage of consumable supplies
14) Lack of intensivist or specialist
15) Lack of Critical acre facilities
Some of the challenges are elaborated
here
1) Shortage of Staffing:
There is a consistent global concern related
to a health care workforce shortage and this
issue is expected to become worse in the
coming decade. There is a clear need for
sophisticated workforce planning at the
local, national and international level.
Mechanisms are needed to help inform
policy makers and governments to pre-
empt and plan for shortages and to manage
over supply carefully to ensue relative
equilibrium across the system.
2. Working conditions (including wages)
It is to agree that having sound working
conditions and wages are important but
other factors like staffing ratios, workloads
and family friendly roster schedules are also
important factors for critical care
specialists. Wealthy countries had
significantly less concern for appropriate
wages and technology while poorer
countries were significantly more
concerned for the standard of facilities and
technology in their countries. High-income
countries offer better remuneration,

9. COURSE I - INTRODUCTION TO CRITICAL CARE PRINCIPLES AND PROCEDURES
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professional advancement and career
opportunities, and a safer working
environment than low-income economies
these matters may also influence the overall
perceptions of working conditions.
3. Access to education programs and
competency training
The WHO emphasizes that the increasing
complexity involved in providing healthcare
and the need to ensure more equitable
access to health care now mandate the need
for global standards for nursing education
and practice (World Health Organization).
Access to education programs has remained
an important issue in all countries,
However, as with wages, it was evident that
the provision of quality education programs
was significantly less important among the
high-income countries compared to others.
This may be attributed to the improved
provision and access to educational
programs in the wealthier countries,
especially through online/ internet access
highlighted in earlier surveys. Health
professionals in countries with low incomes
will need to find appropriate and affordable
ways to improve access to quality education
programs.
The role of the critical care specialist is
essential to the multidisciplinary team
needed to provide specialist knowledge and
skill when caring for critically ill patients to
enhance delivery of a holistic, patient
centered approach. In a high tech
environment bringing to the patient care
team a unique combination of skill,
knowledge and caring. In order to fulfil their
role, require appropriate specialized
knowledge and skills to perform various job
in critical care units.
4. Teamwork
The importance of strong collaborative
teamwork in the critical care environment
is very much essential for inter disciplinary
teams of all critical care units to maintain
patient safety, maintain quality and error
free services.
5. Provision of formal practice guidelines
and competencies
Provision of formal practice guidelines and
competencies has remained an important
issue for critical care units globally and this
was a consistent theme regardless of region
or wealth. It is reassuring that critical care
health professionals are highlighting this
need to promote safety, quality and error
prevention remain important critical issues
in clinical practice throughout the world.
Clinical protocols, workforce and education
standards, and clinical practice guidelines
for common encountered challenges
including but not limited to pediatric
conditions, tracheostomy management,
weaning from ventilation, sepsis
management, pain and sedation
management, delirium management, and
the workplace environment, suggests
critical care specialist practice standards
globally.

10. COURSE I - INTRODUCTION TO CRITICAL CARE PRINCIPLES AND PROCEDURES
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However, it is also clear that huge gaps
between what is required and what exists
remain and policy makers of health systems
throughout the world need to find efficient
and effective collaborative ways to meet
these needs collectively.
SUMMARY
In this unit you have learnt about brief
history, aims, purposes and indications of
Critical care units. You have also learnt
regarding trends and challenges of critical
care units and services.
REFERENCES
 Andrew Web, Derek Angus, Simon
Finfer. Oxford Text book of Critical Care.
2nd edition. Oxford publications.
 Thompson DR, Hamilton DK, Cadenhead
CD, et al. (2012). Guidelines for
intensive care unit design. Critical Care
Medicine, 40(5), 1586–600.
 The Facilities Guidelines Institute.
Guidelines for Design and Construction
of Hospitals and Outpatient Facilities,
(2014) edn. Chicago: American Society
for Healthcare Engineering (ASHE) of
the American Hospital Association.
SELF-ASSESSMENT
1. The following are the concepts of
Critical Care, except _____
A. Cure
B. Comfort
C. Compassion
D. Consistency
2. The need of Critical Care is _______
A. To assess life threatening conditions
B. Initiate appropriate interventions
C. Both A and B
A. None of the above
3. A Critical care professional works with
patients with _____ medical problems.
A. Mild
B. Typical
C. Life-threatening
D. Multiple
4. Critically ill patients require ________
A. Intermediate Care
B. Intensive Care
C. Home Care
D. None of the above
5. The aim of critical care is to provide a
care such that patient improves and
survive the _____________ illness.
A. Acute
B. Chronic
C. Severe
None
KEY
1. A
2. C
3. C
4. B
5. A
SUGGESTED READINGS
 Cadenhead CD and Anderson DC.
(2009). Critical Care Design: trends in
award winning designs. World Health
Design 2009. Available

11. COURSE I - INTRODUCTION TO CRITICAL CARE PRINCIPLES AND PROCEDURES
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at: http://www.worldhealthdesign.com
/ critical-care-design-trends-in-award-
winning-designs.aspx (accessed 3
June, 2013).
 Bartley J and Streifel AJ. (2010). Design
of the environment of care for safety of
patients and personnel: does form
follow function or vice versa in the
intensive care unit? Critical Care
Medicine, 38(8 Suppl.), S388–98.
 Halpern NA. (2014). Innovative designs
for the smart ICU: Part 2. The ICU. Chest,
145(3), 645–58. 9. Nestor C. (2005).
Critical conditions. A real-world look at
features and technologies for the ICU.
Health Facility Management, 18(8), 25-
9.

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