Assessment & Monitoring in ICU Flashcards
Why are patients admitted to ICU?
- For intensive monitoring, support or therapy
- Acute or potential organ system failure
- Appears reversible with provision of intensive support
What types of organ failure are referred to ICU?
- CV (shock, cardiogenic pulmonary oedema)
- Respiratory (hypoxia, hypercapnoea)
- Coma
- Liver
- Renal (kidneys)
- Gut
- Major desquamation of skin
What are the types of admission to ICU?
- Elective (major surgery)
- Emergency (major surgery, multi-trauma, management of severe medical conditions with major organ dysfunction)
What does assessment & monitoring in ICU enable?
- Establish precise diagnosis
- Determine appropriate therapy
- Monitor response to therapy
What are the types of assessment & monitoring in ICU?
- Non-invasive (e.g. BP cuff)
- Invasive (e.g. arterial line)
- Derived (e.g. cardiac index measurement)
What is an APACHE score?
- Acute physiology & chronic health evaluation
- Completed for each patient on admission
- Severity of disease classification based on 12 physiological parameters
- Scores 0-71, higher number = sicker patient
What does CV assessment include?
- Heart rate & rhythm
- Blood pressure
- Central venous pressure (CVP)
- Pulmonary artery pressure
- Pulse induced continuous cardiac output (PiCCO)
- Intra-aortic balloon pump (IABP)
How is heart rate & rhythm assessed?
- 4 leads for continuous monitoring
- Normal 60-100
- Supplemented by 12 lead ECG if more accurate diagnostic info required
How is blood pressure assessed?
- Cuff (non-invasive, intermittent monitoring)
- Arterial monitoring (invasive, continuous)
- Cannula inserted into artery (usually radial)
- ABGs sampled from cannula
What is the arterial line connected to?
Transducer that sits at the level of the patient’s heart
What are the normal blood pressure values?
- 95/60 - 140/90
- MAP = DBP + (SBP-DBP)/3 = 70-90mmhG
What is MAP an indirect measure of?
Adequacy of organ perfusion
How is central venous pressure (CVP) measured?
- Central venous catheter (CVC) inserted into superior vena cava
- Connected to transducer
- Normal = 3-15 cmH2O
What does CVP reflect?
- Hydration
- Venous return
- Right heart compliance
- Intrathoracic pressure
- Posture of patient
What is a pulmonary artery catheter (Swan-Ganz catheter)?
- Used in patients with CV instability
- Passes through right atrium, right ventricle to left/right pulmonary vein
- Connected to transducer, catheter has balloon
What does a pulmonary artery catheter (Swan-Ganz catheter) measure?
- Pulmonary artery pressure (balloon deflated, monitors pulmonary hypertension, normal = 10-20mmHg)
- Pulmonary capillary wedge pressure (balloon inflated, estimate left atrial pressure, normal = 6-15mmHg)
- CO or Cardiac index (via thermodilution technique, normal CO = 51 L/min)
What does increased PCWP indicate?
- Poor LV function
- Hypervolaemia
- Mitral valve disease
What does pulse induced continuous cardio output (PiCCO) monitor?
- CO & other parameters
- Guides fluid & isotrope management
- Requires use of CVC & arterial line (continuous monitoring)
What is an intra-aortic balloon pump (IABP) used to monitor?
- Inserted through femoral artery into aorta
- Used for patients with severe left ventricular failure
- Increases perfusion into coronary arteries during diastole
- Reduces LV afterload & improves CO during systole
What does neurological assessment in ICU include?
- Glascow coma scale
- Intracranial pressure (ICP)
- Cerebral perfusion pressure
What does intracranial pressure (ICP) measure?
- Pressure in the skull
- Influenced by volume of blood, CSF & brain tissue
- Normal <10mmHg
- Critical >20mmHg
How is ICP measured?
- Intraparenchymal sensor
- External ventricular drain (EVD)
What is the dual purpose of an EVD?
Monitors ICP (drain closed) & drains excess CSF/blood from ventricle (drain open)
What is increased ICP?
Potentially fatal cause of secondary brain injury from lack of perfusion to brain tissue
What are the causes of increased ICP?
- Cerebral mas
- Oedema/infection
- Obstructed venous drainage
- Hypercapnia
- Hyperaemia
- Increased production, decreased reabsorption or obstruction of CSF flow
- Posture
What is cerebral perfusion pressure?
CPP = MAP - ICP
- Normal value >70mmHg
- Critical value <55mmHg
What does respiratory assessment of non-ventilated patients include?
- Daily CXR
- ABGs every few hours if arterial line
- High-flow oxygen for very hyperaemic patients
- SpO2
- RR
What does respiratory assessment of ventilated patients include?
- Mode of ventilation (record SIMV)
- RR, TV, FiO2
- PEEP
- PIP
- Humidification
- Interface (mask, ETT, trachy)
- Ability to DB/huff on ventilator
- Amount/quality of sputum on suction
What does GI assessment include?
Type of nutrition
- Nil
- Oral
- Enteral (NG/PEG tube)
- Total parenteral nutrition (TPN) directly into CVC
What does renal assessment include?
Urine output
- Helps to reassess renal perfusion
- Guides adequacy of CO
- Acute renal failure: Rapid rise in urea/creatinine concentration, drop in urine output
What is continuous renal replacement therapy/dialysis?
- Used short term in ICU for patients with acute renal failure
- Removes waste products from the blood
What are the considerations for physio for patients on dialysis?
- Pulmonary oedema may be common (fluid retention)
- Patients may experience a drop in BP after dialysis as fluid is removed
- Dialysis apparatus may be very sensitive to changes in position & intrathoracic pressure
How is fluid balance assessed?
- Measures of intravascular volume (HR, MAP, CVP etc)
- Daily weight
- Daily CXR (check for PO)
- Assessment of peripheral perfusion
- Net fluid balance on ICU flowchart = intake-output
What does haematological & immunological assessment include?
- Coagulation studies (blood tests)
- Prolonged bleeding time (risk of bleeding/bruising during physio)
- Low platelet count
- Low white cell count
- Sepsis
- Malignancy
- Drug therapy
What does musculoskeletal assessment include?
- Muscle length/strength
- Joint integrity
- Presence of fractures
- Neuromuscular function (balance, coordination, sensation)
What are some of the effects of ICU on patients?
- Sleep deprivation/fragmentation
- Fear/anxiety
- Sensory deprivation
- Discomfort
- Sensory overload
- Communication difficulties
- Helplessness
- Dependency & depression
- Loss of privacy, dignity & identity
- Sensory monotony & loss of time
What are some of the after effects of ICU on patients?
- Impaired mobility
- Continuing pain
- ICU syndrome
- PTSD
- Compression neuropathies
- ICU acquired weakness
- Fear of falls
- Anxiety/depression
- Decreased fitness
- Inspiratory muscle weakness
What is the role of physio in ICU?
- Respiratory
- Exercise, strengthening, positioning (early rehab)
- Mobilisation
