CRITICAL CARE

Improving outcomes…

On 07th October, 2014

At :M P Shah Medical College, Jamnagar
What is ICU??
 CRITICAL CARE

THE PAST

key figures and events associated with the origin of critical care
medicine and development of ICUs…..
 During the Crimean War in the 1850s,
Florence Nightingale demanded that
the most seriously ill patients were
placed in beds near to the nursing
station so that they could be watched
more closely, creating an early focus on
the importance of a separate
geographical area for critically ill
patients.
 In1923, Dr Walter E Dandy opened
a special three-bed unit for the
more critically ill postoperative
neurosurgical patients at the Johns
Hopkins Hospital in Baltimore, MD,
USA, using specially trained nurses
to help monitor and manage them.
Phillip Drinker
 Harvard (1927): Iron lung
developed and presented
in article titled “The use of
a new apparatus for the
prolonged administration
of artificial respiration: A
fatal case of poliomyelitis”

 Donation to Bellevue
Hospital where it saved a
woman dying from
overdose of an unknown
compound
 In 1930, Dr Martin Kirschner designed
and built a combined postoperative
recovery/intensive care ward in the surgical
unit at the University of Tubingen, Germany.

 Other surgical units followed these

examples, such that by 1960 almost all
hospitals had a recovery unit attached to
their operating rooms.
 During the Second World War,
specialized shock units were
used to provide efficient
resuscitation for the large
numbers of severely injured
soldiers

 In the 1950s, several large polio

epidemics, notably in
Copenhagen, led to the opening
of respiratory units for the
many patients requiring
mechanical ventilation
ICU Before 20 years
 Earlier ICUs’ Environment
 Early ICUs were somewhat isolated, slightly
mysterious, and rather frightening places;
staff and visitors (when allowed) were often
gowned with protective shoe covers, even masks
- adding to the sense of anxiety for the patient
and their families.

 Patients were often heavily sedated to facilitate

mechanical ventilation and in the belief that this
approach would reduce patient agitation and
discomfort.
 Visiting hours were highly restricted to
avoid any increase in physiologic stress for
the patient, any interference with the
provision of care, and to limit the spread of
infection in these vulnerable patients

 Many of the initial critical care units were

staffed by physicians whose primary
specialties were in anesthesiology or
internal medicine.
 Peter
Safar
 First intensivist doctor
 Received anesthesia training at
Penn
 Started “Urgency and
Emergency Room”—now
known as ICU in 1958
(Baltimore)
 Artificial ventilation, cardiac
massage became popular
 Father of cardiac resuscitation
 1962—Pittsburgh establishes
first critical care fellowship
What is Critical Care Medicine ?
Critical Care Medicine …
 A young Superspeciality…

 Superspeciality of the young??

 The Heart of any Hospital…

The Essence of Critical
Care…?
 Saving lives

…. The Essence of Medicine

…You are expected !
Critical Care in Clinical
Practice
 Saving lives through Critical Care
Cardiology Trauma Dermato
One Point Contact:
Intensivist
Any acute disruption in normal physiology
 Trauma
 Stroke
 Acute Cardiovascular Instability
 Acute Kidney Injury
 Acute Respiratory Failure
 Septicemia
 Complicated Pregnancy
 Poisoning
 Acute Bleeding
 Acute Liver Failure/ Pancreatites
 All High End Surgical perioperative Care
Intensivist role
 Physician
 Cardiologist
 Pulmonologist
 Sonologist
 Nephrologist
 Gastrenterologist
 Trauma care
 Toxicologist
 Administrator
Critical Care Medicine…
 Treat patient as a whole…

 Look after the patient 24 X 7…

 Time is Life…
ICUs in Hospitals…
Yesterday Today
Tomorrow
Concept of Open and Closed ICU
 The majority of units were OPEN, with patients managed
by their primary admitting physician, so that different
patients on a single ICU would be managed by different
physicians.

 Later, it was realized that many ICU patients had similar

problems, regardless of the reason for their critical
illness, and that CLOSED UNITS, in which patients were
managed by a team of specially qualified intensive care
physicians and nurses, provided patients with better care
and were associated with improved outcomes
CRITICAL CARE – THE PRESENT
Human Physiology: our body works well
only if all systems of the body work well
Inter-dependance of Organ System
For example:-

1. If left ventricle of the heart not working

well then pulmonary edema develops and
patient become breathless

2. If severe COPD than patient may develop

pulmonary hypertension and right ventricular
failure.
3. If patient’s CNS is not working well and GCS
is low then patient may develop aspiration
pneumonia.

4.If patient having low cardiac output, patient

may develop pre renal failure and if patient of
renal failure develops metabolic acidosis then
patient become tachypneic.
Airway and Breathing
 Mechanical Ventilation
 Mechanical
ventilators are much smaller,
more mobile, and more user-friendly
Modes of ventilator
 Recent modes of ventilator
significantly reduces the time of
the physician and nurse without
harming the patient

 VC,
PC, SIMV, PS, PRVC, VAPS, PAV,
ASV, ATC, BIPAP, APRV, NAVA to
name a few…..
Circulation
 Protocols for managing Shock of all etiology
with focus on diagnosis and simultaneous
resuscitation

 The development of portable ultrasound

units and other non-invasive or less-
invasive monitoring techniques has
decreased the need for pulmonary artery
catheter insertion
Current ICUs Environment….

 Management have become less, less

interventional, and more humane.

 Units are less strict and more friendly and

welcoming for the patient and family than in
the past
Multi-disciplinary approach towards
patient care
 Intensive care specialist aggressively monitors
and manages all Patients round the clock

 Liaison with
◦ Physicians with relevant specialist
◦ Pharmacist
◦ Nutritionist
◦ Microbiologist
◦ Physiotherapist
◦ Infectious Disease specialist
Antimicrobial Issues
 Local, regional and international surveillance
system to monitor bacterial resistance and
microbiological patterns

 Rigorous protocols to prevent and treat

infections
Anabolic/anti-catabolic therapy in critical illness

 Critical illness progresses through acute,

chronic, and recovery phases, each with their
different nutritional demands and
susceptibilities.

 The ICU experience undergone by many normal

individuals is not unlike the stresses
encountered by elite athletes during training
and competition.
Nutrition in Critically ill…
 Use well-timed nutritional and hormonal
interventions to improve immunological and
neuromuscular responses.
 Use high-dose protein (1.5 to 2.0 g/kg/day),
exercise (that is, early ambulation of ventilated
patients), and hydroxymethyl butyrate during the
acute phase, with no potent anabolics.
 In the later phases, use sufficient calories and
high-quality protein, β-blockers, and
hydroxymethyl butyrate complemented by
oxandrolone and creatine.
 In the recovery phase, add low doses of
growth hormone to this prescription.

 Delivering sufficient calories and protein

in the chronic and recovery phases of
critical illness is mandatory if
oxandrolone, growth hormone, or other
anabolic agents are to be both safe and
effective.
 Primary role in managing various
diseases
 Various studies recommend that admission
under an intensivist has been associated with

 Overall Outcome
 Morbidity (ICU, 30-day, hospital) 
 Cost 
 Length of stay (ICU, hospital) 
 Complication 
Evidence Based Practice:
2014
 Especially for Pulmonary artery catheter, use of
albumin, blood transfusion

 Use of lower tidal volumes

 No benefit from low dose dopamine as a renal

protector

 Decreasing Use of sedatives

Attempts to form clear definitions
 ARDS

 SEPSIS

 Complex ICU syndromes

 Standard

Protocols
ICU’s also treat the dying
 Isaac Asimov: “Life
is pleasant. Death
is peaceful. It is the
transition that is
difficult”
CRITICAL CARE – THE FUTURE
Key challenges for future
 Adequatelytrained medical and
paramedical staff to cater for the
increased numbers of patients
 Options proposed for the challenge
 Greater use of computerized, nurse-run protocols
to manage patients;

 Regionalization of intensive care so that trained

staff are concentrated in several larger units, which
will provide greater staffing flexibility and may
offer improved patient outcomes;

 Use of telemedicine to enable a trained doctor from

a larger institution to provide assistance to less
well-staffed, smaller units
Future – in terms of
technology
 Immediate online availability of the
patient’s records world wide
 Prescriptions and tests will be

increasingly ordered, viewed, and

analyzed via handheld digital assistants
or bedside screens, facilitating diagnosis
and helping to limit drug errors.
Tele-ICU
From Molecular to
Genomics…
 Continued developments in genomics,
proteomics, and metabolomics will lead to better
characterization of patients and their ongoing
and underlying disease processes, facilitating
diagnosis, prognosis, and therapeutics.

 Continued study will also reveal better treatment

targets, which may include microcirculatory
measures, cellular markers, and so forth.
Real time stethoscope
 Stethoscope with a ultrasound waves and
a screen for real time monitoring of –
lungs, heart, IVC, liver, spleen, optic
nerve etc…

 Similar to the use of

ultrasound in emergent
situations
Targeting the microcirculation to
improve the outcome
 Target the microcirculation as the primary objective.
 Directly visualize representative microcirculatory beds

to monitor progress toward the goal of achieving

adequate perfusion and oxygenation.

Utilize the drugs and fluids that are

effective in oxygenating and
perfusing the microcirculation
(goal-directed fluid therapy plus
blood transfusion),
 opening the microcirculation (for example,
sodium nitrite, a pure nitric oxide donor with
potential for releasing nitric oxide from
hypoxic red blood cells in compromised
tissues),
 preserving the cellular
 glycocalyx (for example, vitamin C),
 providing potent actions at the

microcirculatory level.
 Complimentary and alternative
medicine
 CAM (complimentary and Alternate Medicine)
have been recognized as helpful in relieving
stress, anxiety, discomfort, restlessness, and
insomnia.

 Use of these techniques routinely, to accomplish

effective sleep, pain relief, and the sense of well-
being that may accelerate rehabilitative progress
and reduce the consequences of drug-based
management.
Use of pro-, pre-, symbiotics
 Normal protective layer in GIT, respiratory, skin,
vagina and eyes
 Absent in critically ill patients
 Supply of both pre- and probiotics can modify
functions such as appetite, sleep, mood and circadian
rhythm, and this most likely through metabolites
produced by microbial fermentation in the gut.

 Eco-immunonutrition with pre- pro- and synbiotics

offer to be suitable tools in the new millennium.
In terms of technology
 Modern respirators replacing the bulky
iron lungs of the past
 Modern ultrasound machines

providing instant imaging at the

bedside
 Modern monitoring systems enabling

non-invasive assessment of multiple

variables
CRITICAL CARE - Summary
 Improvements in our understanding of diseases and
their patho-physiology.
 Advances in therapeutics have been less dramatic
and are less obvious,
 Evolution has come in a succession of small
forward-moving steps.
 Improved teamwork and specialist training, reduced
iatrogenicity, earlier patient mobilization, more
personal care of the patient and their families, and
so forth.
 Topic #2
Updates on
resuscitation
History of Resuscitation (BLS & ACLS)

 1947—Claude
Becker invents
first defibrillator

 1947—1st life
saved with
debrillator
1957
Airway & Breathing Management
 Newer devices
Difficult Airway backup in
Standard Critical Care Unit
 Airway Adjuncts
 BMV
 Bougies
 LMAs’
 Combitubes
 Cricothyotomy set
 Tracheostomy set
Airway & Breathing Management
 Newer devices

 Role of ETCO2

 Modern Ventilators

 Emergency Cricothyrotomy
New Modality To Improve Oxygenation

 Prone Positioning

 Nitric Oxide Inhalation,

 Extra Corporeal CO2 removal,

 Extra Corporeal Membrane Oxygenation
ECMO – Extracorporeal membrane
oxygenation
Synchrony with NAVA
High frequency Oscillator : HFO
Shock Resuscitation
 Large Bore IV Cannula v/s central lines

 Crystalloids v/s Colloids

 NS v/s RL v/s Albumin

 How Much Fluid ??

Vaso Active Agents…
 Inotropes & Vasopressors

 Noradrenaline

 Adrenaline

 Dopamine

 Dobutamine

 Vasopressin & Levosimendan

Monitoring resuscitation…
 HR & BP & U/O

 Sensorium & GCS

 Lab Tests

 Bedside Monitors

 Imaging techniques
CARDIAC OUTPUT MONITORING
 Ultrasound in Critical Care
Diagnostic

 Airway patency & deviation

 Pleural effusion, pneumothorax, consolidation
 Pulmonary embolism
 LV failure, pulmonary edema
 Fluid responsiveness
 DVT
 Intraperitoneal bleed
•Therapeutic
 Central venous access, Arterial line insertion

 ICD insertion

 Thoracocentesis and abdominal paracentesis

 Positioning of IABP and PA catheter

 Cricothyroidotomy, PCT

•Assessment
 Fluid status

 Lung recruitment

 Resolution of pneumothorax
Current role in Critical Care
 Airway with prediction for intubation
difficulty
 Breathing with lung pathology detection
 Circulation with echocardiography
 FAST
 DVT
 Pupils and Optic Nerve (ICP)
 Procedure assistance