Chapter 12 - Introduction to ICU

Question 1

Give some common medical reasons to be in ICU

Answer 1

RESPIRATORY FAILURE REQUIRING MECHANICAL VENTILATION

• PNEUMONIA (CAP/HAP/VAP) • AECOPD
• ARDS
• FLU

RENAL FAILURE (COMMON IN GI BLEEDS, SEPSIS, NEPHROTOXICITY, AND HYPOTENSION)

METABOLIC DYSFUNCTIONS

INFECTION→ SEPSIS (MOST COMMON PREDISPOSING FACTOR TO MULTISYSTEM ORGAN FAILURE)

Question 2

Give some common surgical reasons to be in ICU

Answer 2

COMPLEX SURGERIES (EX: Whipple, Sugarbaker, transplants, AAA’S)

PAIN CAUSING COMPLICATIONS
• Rapid/shallow breathing to avoid

coughing/pain

• Atelectasis can develop due to the absence of deep breaths

HYPOXEMIA

• Alveolar hypoventilation, reduced FRC, airway closure, post-surgical atelectasis

Question 3

Give some common neuro/neurosurgery reasons to be in ICU

Answer 3

CONDITIONS THAT REQUIRE VASOPRESSORS OR INVASIVE VENTILATION INCLUDING:

• POST STROKE (ISCHEMIC OR HEMORRHAGIC)
• ACQUIRED BRAIN INJURY (ABI)/TRAUMATIC

BRAIN INJURY (TBI)

• NEUROMUSCULAR CONDITIONS
• GUILLAIN-BARRE SYNDROME, MYASTENIA GRAVIS, ETC.

UNSTABLESPINE/SCI
-HIGHER LEVEL SCI OFTEN REQUIRE INTUBATION

AND POSSIBLY TRACHEOSTOMY

BRAIN ANEURYSM REPAIRS

TUMOR EXCISIONS

Question 4

Give some common cardiovascular reasons to be in ICU

Answer 4

• POST-OP HEART TRANSPLANT
• POST-OP CABG
• POST-OP VALVE REPAIRS
• MVR, AVR, ~TAVI
• SEVERE HEART FAILURE

(LVAD/BIVAD PATIENTS)

Question 5

Other reasons to be in ICU

Answer 5

• TRAUMA
POTENTIAL CRUSH AND PENETRATING CHEST INJURIES (RIB FRACTURES)

RISK OF CARDIOVASCULAR AND PULMONARY FAILURE

• BLOOD OR AIR IN CHEST CAVITY

IMPAIRS VENTILATION

• PNEUMOTHORAX OR HEMOTHORAX

AIR OR BLOOD IN PLEURAL CAVITY (REMOVED WITH CHEST TUBE)

COMPROMISES LUNG EXPANSION

Question 6

WHY are patients in the ICU?

Answer 6

MULTISYSTEM INVOLVEMENT

HIGH ACUITY, COMPLEX PATIENTS

CONTINUOUS MONITORING

PHARMACOLOGICAL IMPLICATIONS
• SEDATIVES, ANALGESICS, INOTROPES, VASOPRESSORS, PAFRALYTICS, ANTIPSYCHOTICS

MECHANICAL VENTILATION AND OTHER EQUIPMENT NEEDS

• CENTRAL LINES, CRRT, ECMO, ETC.

STAFFING STRUCTURE

Question 7

Which patients are NOT in the ICU?

Answer 7

PERSONAL DIRECTIVE

• DELEGATE AND INSTRUCTIONS

CODE STATUS

• FULL CODE vs. NO CODE (DO NOT RESUSCITATE) vs. COMFORT CARE

Question 8

Give examples of people who are in the ICU team

Answer 8

• MULTIDISCIPLINARY TEAM:
• INTENSIVIST & RESIDENTS
• ADJUNCT SPECIALISTS
• CRITICAL CARE NURSES
• RESPIRATORY THERAPISTS
• PHARMACISTS
• PHYSIOTHERAPISTS
• OCCUPATIONAL THERAPISTS
• DIETITIANS
• SOCIAL WORKERS
• SUPPORT STAFF (CARE TEAM ASSISTANTS, UNIT AIDES)
• FAMILIES

Question 9

Name some of the 10 possible lines

Answer 9

1) Arterial line
2) Central line
3) Feeding tube (G-tube/NG/OG)

4) PICC
5) PIV
6) Vascatheter
7) Chest tube
8) Foley catheter/rectal tube
9) Drains (hemovac/j-pratt/perc)

10) Vac dressing

Question 10

WHY PT IS IN THE ICU: ICU- ACQUIRED WEAKNESS (ICUAW). What is ICUAW?

Answer 10

• ICUAW Definition: “clinically detected weakness in critically ill patients in whom there is no plausible aetiology other than critical illness”
• critical illness polyneuropathy (CIP)
• critical illness myopathy (CIM)
• critical illness neuromyopathy (CINM)

Question 11

In general, what are some risks of immobility?

Answer 11

Question 12

What are some risks immobility regarding respiratory function?

Answer 12

↓ SECRETION MOVEMENT
↓ RESPIRATORY MOVEMENT
↑ DEPENDENT EDEMA
↓ ARTERIAL OXYGEN SATURATION
↑ RISK OF ATELECTASIS, PULMONARY EMBOLISM, AND PNEUMONIA

Question 13

What are some risks immobility regarding cardiovascular function?

Answer 13

↑ HR REQUIRED TO MAINTAIN RESTING VO2 (~10BPM AFTER 4 WEEKS BED REST)

↓ SV (APPROX 28% AFTER 10 DAYS BED REST – COMPENSATED BY ↑ EF)

CARDIAC DECONDITIONING: V02 MAX ↓ 0.9% PER DAY

ORTHOSTATIC INTOLERANCE: ↓ BARORECEPTOR SENSITIVITY, ↓ BLOOD VOLUME, ↓VENOUS RETURN AND SV, ↓ VENOUS DISTENSIBILITY

↑ RISK OF DVT

Question 14

What are some risks immobility regarding skeletal muscle function?

Answer 14

ATROPHY AND PROTEIN LOSS DURING CRITIAL ILLNESS:

3-4 % REDUCTION IN CROSS-SECTIONAL AREA OF MUSCLES PER DAY (2% ATROPHY PER DAY OF SIMPLE BED REST)

↓ STRENGTH: 3-11% PER DAY

1 DAY IN BEDà2 WEEKS OF REHAB NEEDED TO RESTORE BASELINE STRENGTH

Question 15

What are some risks immobility regarding integumentary system function? What are some for skeletal system? For neuro/cognitive system?

Answer 15

INTEGUMENTARY SYSTEM

PRESSURE INJURIES

SKELETAL SYSTEM

BONE DEMINERALIZATION

6MG/DAY CALCIUM = ~2% BONE MASS/MONTH (UP TO 2 YEARS TO RECOVER)

NEURO/COGNITIVE SYSTEM

DELERIUM

Question 16

What is delirium?

Answer 16

Disturbances of consciousness with reduced ability to focus or sustain attention

Not due to an already pre-existing, established or evolving dementia

Develops over a short period of time and can fluctuate

Types: Hyperactive, hypoactive and mixed

Question 17

Delirium: what’s the big deal?

Answer 17

• It affects up to 80% of ventilated patients!
• Increases mortality
• Lengthens hospital stay
• Increases likelihood of discharge to a Long Term Care facility
• Increases chance of developing dementia by 8x within 48 months

Question 18

Delirium: what are we doing about it?

Answer 18

Interprofessional team approach

Routine assessment of CAM-ICU

Promotion of sleep and least restraint

Assessment of risk factors (ex: medication review)

Early mobility!

• Proven to reduce the incidence and duration of delirium!

Question 19

What are three ways delirium is different than dementia?

Question 20

What are three ways delirium is similar to dementia?