1. WELCOME AND GREETINGS TO ALL

3. Corridor….

4. Inside ICU

5. Inside ICU

6. ICU Beds Inside

8. Inauguration…..

9. ICU
What does it mean???
Intensive care units (ICU),
also called
critical care unit or
intensive therapy unit or
Intensive Treatment Unit (ITU)

10. ICU Are sections within a
hospital
That look after patients:
whose conditions are life-threatening and
need constant, close monitoring and
support from equipment and
medication
to keep normal body functions going.

11. A person in an ICU needs constant medical
attention and support to keep their body
functioning.
They may be unable to breathe on their own
and have multiple organ failure.
Medical equipment will take the place of
these functions while the person recovers.

12. Intensive care is often needed
when one or more of your organ
systems have failed.
For example, this might be your:
• lungs
• kidneys
• heart
• digestive system

13. Conditions and situations that can
cause your organ systems to fail
• a serious accident – such as a road
accident or a severe head injury
• a serious acute (short-term) health
condition – such as a heart attack (where
the supply of blood to the heart is
suddenly blocked), or a stroke (where the
blood supply to the brain is interrupted)

14. Cont…..
• a serious infection – (SIRS) such as
a severe case of pneumonia (inflammation
of the lungs) or sepsis(blood poisoning)
• major surgery – this can either be a
planned admission to an ICU as part of
your recovery after surgery or an
emergency measure if there are
complications during surgery

15. Intensive care units (ICUs)
contain a variety of specialized
equipments, which may vary
from one unit to another.
A series of tubes, wires and cables connect
the patient to various equipments, which
may look alarming at first.
Sounding and beeping of these may puzzle
the patient and attendants.

16. Main ICU machines
Ventilator
Monitoring equipments
• heart and pulse rate (measured by an
electrocardiogram or ECG)
• air flow to your lungs
• blood pressure and blood flow
• pressure in your veins (known as central venous
pressure or CVP)
• the amount of oxygen in your blood
• your body temperature

17. Main ICU machines (Cont…)
IV lines and pumps
• sedatives – to reduce anxiety and
encourage you to sleep
• antibiotics – medication that is usually
given in high doses and used to treat
infections caused by bacteria
• analgesics – also known as painkillers
• Inotropes
• Insulin

18. Main ICU machines (Cont…)
Kidney support
Respiratory support
Feeding tube
Drains
Catheters
Suction pumps
Others

19. Recovery
Once you are able to breathe unaided, and you
no longer need intensive care and you will be
transferred to a different ward to continue
your recovery. (HDU)
Only Recoverable, acute condition patients are
suitable candidate for ICU. Chronic, end stage
diseases are not usually suitable…….

20. Common recovery problems
Severe weakness and tiredness
Loss of weight and muscle strength
Weak voice
Inability to grip small items
Feeling depressed
Cognitive function

21. Levels of Care
"Comprehensive Critical Care" defined four
different levels of care:
• Level-0
Patients whose needs can be met through
normal ward
• Level-1
Patients at risk of their condition deteriorating, or
higher levels of care whose needs can be met
on advice and support from the critical care
team.
• Level-2
Patients requiring more detailed observation or
intervention, single failing organ system or
postoperative care, and higher levels of care.

22. Levels of Care (Cont..)
Level-3
Patients requiring advanced respiratory
support alone or basic respiratory support
together with support of at least two organ
systems. This level includes all complex
patients requiring support for multi-organ
failure.
High dependency can refer to level 1 or 2
whereas intensive care usually means
level 2 or 3.

23. Historical Backgrounds of ICU
concepts
800 BC: Prophet Elisa- mouth to mouth…
460-70 BC: Hipocrates- 1st Endo-tracheal
Intubation…(Treatise on air)…
1550: Paracelsus used “Fire Bellows”, 1 st
concept of mechanical ventilation.
1774: John Fothergill- mouth to mouth….
1774: Dr. William Haves establish “Royal
Humane Society” contributed much…

24. Historical Backgrounds of ICU
concepts (Cont…)
High pressure-tension pneumothorax…
1837: manual compression of chest…
1864: Dr. Alfred Jones devised “tank
Ventilation” known as “Iron lung”.
1889: Alexander Graham Bell devised a
vacuum jacket……
1929: Philip Drinker devised electrically
powered tank ventilator, “iron lung”…

25. Historical Backgrounds of ICU
concepts (Cont…)
Later developed cuirass
All these (tank & cuirass) were negative
pressure ventilators
1st recorded concepts of ICU are paralytic
poliomyelitis epidemics in …….
1948: Los Angels
1952: Scandinavia

26. Historical Backgrounds of ICU
concepts (Cont…)
1952: Denmark (severe epidemics)- Ambu
by medical students plus tank and cuirass.
All were managed by negative pressure
ventilations….
Lassen and Ibsen: basic principle of IPPV
with modern ventilation (volume, pressure,
humidification, oxygen and physiotherapy)
1955: Stockholm and New England
epidemics-IPPV…..
1960: IPPV, its superiority and CVS effect.

27. Mechanical Ventilation (1)
• Use of a machine to take over active
breathing for a patient
• Used for patients who are unable to
sustain the level of ventilation
necessary to maintain the gas
exchange functions - oxygenation and
carbon dioxide elimination

28. Ventilator in RpMCH ICU

29. Mechanical Ventilation (2)
Goals:
•
Increase efficiency of breathing
•
Increase oxygenation
•
Improve ventilation/perfusion relationship
•
Decrease work of breathing
Indications:
A. Established acute respiratory failure
B. Incipient respiratory failure
C. Low output states
D. Purposeful hyperventilation

30. Mechanical Ventilation (Indications)
A) Established Acute Respiratory Failure
 Primary ventilatory failure
– Poisonings which depress the CNS
– CNS and neuromuscular disorders
( poliomyelitis, infective polyneuritis, myasthenia)
– Snake bites
– Severe tetanus
 Hypoventilating comatose patients
 Acute pulmonary disorders e.g. fulminant pneumonia,
acute lung injury (ARDS)
 Fulminant pulmonary oedema
 Major or massive pulmonary embolism
 Major or massive atelectasis
 Patients with COPD in acute crisis, unresponsive to
conventional therapy
 Patients with acute severe asthma , unresponsive to
conventional therapy

31. Mechanical Ventilation (Indications)
B) Incipient Respiratory Failure
 Obese patients who have undergone upper abdominal
surgery, or poor risk surgical patients
 Respiratory muscle fatigue in critical illnesses
 Patients with excessive ventilatory demands
 Patients with acute fulminant parenchymal lung disease
with rapidly progressive impairment of pulmonary function
and reserve
C) Low output states
 Shock of any etiology
D) Purposeful hyperventilation
 To decrease intracranial tension in patients with head
injury
 To reduce cerebral edema after CPR or massive CVA

32. Commonly used modes of
mechanical ventilation
•
•
•
•
•
•
•
•
Controlled mandatory ventilation (CMV)
Assist control ventilation (ACV)
Synchronized intermittent mandatory
ventilation (SIMV)
Pressure support ventilation (PSV)
Positive end expiratory pressure (PEEP)
Continuous positive airway pressure (CPAP)
Bilevel positive airway pressure (BIPAP)
Intermittent mandatory ventilation (IMV)
Pressure control ventilation (PCV)

33. Monitoring Mechanics
Pressure, flow, and volume
Time‐ based graphics (waveforms)
– Pressure
– Flow
– Volume
Derived measures
– Compliance
– Resistance
Loops
– Pressure volume
– Flow volume

34. analgesia
Sedation
Muscle
relaxation
Nutrition
Care of a patient on
respiratory support
Preventing
complications
Chest infections
Venous thrombosis
Pulmonary embolism
GI bleed
Care of
vascular lines
and tubes
Care of lungs
Care of
unconscious
patient
Psychological
care

35. Pulmonary
Pulmonary barotrauma
Chest infection
Venous thrombosis
Pulmonary embolism
Lung fibrosis (late)
Alveolar hyperventilation
Atelactasis
Gastrointestinal
Pneumoperitoneum
Decreased GI motility
Gastrointestinal haemorrhage
Complications of
mechanical
ventilation
Cardivascular
Decreased cardiac output
Dysrhythmias
Pulmonary artery
catheter complications
Others
Bacteremia
Multiorgan failure
Psychological
consequences
Endocrine
dysfunction
Pressure sores
Nutritional
Malnutrition
Excess CO2 production
Renal
Fluid retention
Renal failure

36. Weaning
• Process of withdrawal of mechanical
ventilatory support that transfers the work of
breathing from ventilator to the patient
• This period may take many forms ranging
from abrupt to gradual withdrawal from
ventilatory support
• The aim of ventilatory support is to unload the
patient’s respiratory pump, while weaning is
the process of reloading the respiratory pump

37. Increased cost
Increased
risk of VAP
Decreases the
availability of ICU
beds
Why Wean
early ???
Increased hospital
length of stay
Increased ICU
length of stay
Increased morbidity
& mortality
Can adversely
affect the
patient outcome

38. Weaning Criteria
Clinical Criteria
• Adequate cough
• Absence of
excessive
tracheobronchial
secretions
• Resolution of the
disease acute
phase for which the
patient was
intubated
Objective Criteria
• Ventilatory criteria
• Oxygenation
criteria
• Pulmonary reserve
• Pulmonary
measurements
• Other factors

39. Basic monitoring requirements
for seriously ill patients
•
•
•
•
•
•
•
Heart rate
Blood pressure
Respiratory rate
Pulse oximetry
Hourly urine output
Temperature
Blood gases

40. Non-Invasive Monitoring
– Clinical variables
– BP
– ECG
– Echocardiography
– Esophageal doppler
– Gastric tonometry

41. Invasive Monitoring
– Arterial line
– Systolic pressure variation
– Central venous pressure
– Pulmonary artery catheterization
– Cardiac output
– Mixed venous oxygen

42. Maintaining Homeostasis to
allow time for recovery
Continuous or repeated observation +
vigilance in order to maintain homeostasis

43. Standard ICU personnel
Crit Care Med 2003; 31(11):2677–2683
• Vary significantly from hospital to hospital
• With respect to structure, services provided,
personnel and their level of expertise, and
organizational characteristics.
• Based on economic and political factors
• Depend on the population served, the services
provided by the hospital and by neighboring
hospitals, and the subspecialties of physicians
on the hospital’s staff

44. Standard ICU personnel (cont..)
Crit Care Med 2003; 31(11):2677–2683
Large medical centers frequently have multiple
ICUs:
• Cardiothoracic surgical ICUs,
• Trauma ICUs,
• Coronary care units, and
• Neurologic/ neurosurgical ICUs.
• NICUs
Small hospitals may have only one intensive
care unit designed to care for a large variety
of critically ill patients including adult and
pediatric populations. (RpMCH???)

45. ICU personnel in RpMCH
No post of Doctors till now….(needs post
creation)
Inadequate trained nurses…..
No organizational (Organogram) settings till
now…
……………………

46. ICU admission Criteria
(Adapted from McQuillan et al BMJ
1998;316:1853-8.)
• Threatened airway
• All respiratory arrests
• Respiratory rate ≥40 or ≤8 breaths/min
• Oxygen saturation <90% on ≥50% oxygen
• All cardiac arrests
• Pulse rate <40 or >140 beats/min

47. ICU admission Criteria (Cont)
(Adapted from McQuillan et al BMJ
1998;316:1853-8.)
• Systolic blood pressure <90 mm Hg
• Sudden fall in level of consciousness (fall
in Glasgow coma score >2 points)
• Repeated or prolonged seizures
• Rising arterial carbon dioxide tension with
respiratory acidosis
• Any patient giving cause for concern

48. Multidisciplinary Approach
Acute organ failure (Recoverable)- ICU
Main disease- concerned to respective
department
Any additional problem- to be concerned
with respective specialty.
X-ray technicians, physiotherapists etc are
also concerned.

49. Mortality rate and expectations
Rigon et al. Critical Care 2006 10:R5 doi:10.1186/cc3921
Characteristic
Overall population
Autologous stem cell transplantation
Clinically documented lung disease
Absence of congestive heart failure
Neurological impairment
Neutropenia
Unknown cause of acute resp failure
Acute respiratory distress syndrome
Hospital mortality
97/203 (47.8%)
19/29 (65.5%)
17/27 (63.0%)
3/25 (12.0%)
36/52 (61.2%)
41/71 (57.8%)
24/42 (57.1%)
29/40 (72.5%)

50. Brain death and Medicolegal
Aspects
• Cardiac death:
– Heartbeat and breathing stop
• Brain death:
– Irreversible cessation of all functions of the
entire brain, including the brain stem

51. Organ donation
• Call LifeLink for all deaths
– Donor or not in your eyes
– Tissue – bone, corneas, heart valves
• Mentioning organ donation to family
– LifeLink will approach them after declared, but this
approach may (will) be changing back to times when
the PICU docs talked with the parents
• If family asks you about donation
– Acknowledge that it is a wonderful gift they are
considering
– Tell them you will contact LifeLink to have them
available for questions
– Contact LifeLink ASAP

52. References
1.
2.
Egan’s – Fundamentals of Respiratory Care 9th ed.
International Anaesthesiology Clinics – Update on
respiratory critical care, vol 37, no 3, 1999.
3. David W Chang, Clinical application of mechanical
ventilation 3nd ed
4. Paul L Marino, The ICU Book, 3rd ed.
5. Farokh Erach Udwadia-Principles of Critical Care, 2nd ed.
6. Joseph M Civetta,Critical care, 3rd ed.
7. Keith Sykes,JDYoung – Respiratory Support in Intensive
Care BMJ Publishers,2000
8. PKVerma – Mechanical Ventilation and nutrtion in Critically
Ill Patients ,1999
9. Curves and loops in mechanical ventilation – Manual by
Drager Medical
10. BiPAP - Manual by Drager Medical