Management of the Critically Ill Patient

1
Management of the Critically Ill Patient
2
Guidelines

• Regular review of monitored trends and response
  to therapy
• Reassess the care plan
• Adjust prescriptions
• Respiratory Care
• Assisted cough, deep breathing, and alveolar
  recruitment techniques
• Suctioning/trach care

3
Guidelines, cont

• Cardiovascular Care
• Prolonged immobility impairs autonomic vasomotor
  responses to sitting and standing
• Causes postural hypotension
• GI Care
• Supine positioning predisposes to reflux and
  aspiration
• Maintaining a 30 degree head-up position reduces
  this
• Early enteral feeding reduces infection, stress
  ulcers, and GI bleeds
• Immobility is associated with gastric stasis and
  constipation

4
Guidelines, cont

• Neuromuscular
• Immobility, sedation, and paralysis promote
  muscle atrophy, joint contractures, and foot drop
• Splints and PT can help
• Comfort and Reassurance
• Anxiety, discomfort, and pain must be recognized
  and relieved
• Clocks help patients maintain day/night pattern

5
Guidelines, cont

• Communication
• Repeated explanations and reassurance may be
  needed due to medication use
• Use communication aids
• Venous Thrombosis
• Immobility, trauma, sepsis, and surgery
  predispose to deep vein thromboses
• Mechanical and pharmacological treatment can help
  prevent PE

6
Guidelines, cont

• Infection Control
• HANDWASHING!!
• Standard Precautions
• Thorough cleaning between patients
• Skincare/Hygiene/Mouthcare
• Pressure sores can develop due to pressure,
  friction, malnutrition, edema, ischemia, and
  damage from moist/soiled skin
• Turning every 2 hours helpsspecial beds can
  assist with turning
• Mouth care and general hygiene are essential

7
Guidelines, cont

• Fluid/Electrolyte Balance
• Regularly assess fluid balance
• Maintaining normal blood sugar improves
  outcomes/speeds recovery
• Bladder care
• Catheters can cause urethral ulcers
• Catheters can also promote UTI
• Dressing/Wound Care
• Replace dressings regularly, following proper
  technique

8
Guidelines, cont

• Family
• Family members get info from all different
  caregivers with varying levels of understanding
  and expertise, which can be confusing
• There should be only a few primary contacts to
  keep information giving consistent and
  appropriate
• Treat family compassionately they are worried
  about their loved one and may act inconsiderately
• Visiting Hours
• Some units restrict visits to allow for rest
  others dont

9
Organization

• There are 5 basic levels of care
• Level 3 ICU
• Level 2 Intermediate/Stepdown areas
• Includes PACU/RR, ED
• Med/Surg areas
• Level 1 admission wards
• Overlaps with level 2 a lot
• General wards
• Minimal care wards

10
Admission/Discharge

• Guidelines can facilitate use of resources and
  processing of patient through the facility
• diagnosis, severity, likely success of tx,
  comorbid illness, life expectancy, quality of
  life, and patient/family wishes need to be
  considered
• If there is uncertainty, admit the patient
• Discharge should occur when the patient is
  physiologically stable and the reason for
  admission has been resolved

11
Scoring Systems

• APACHE II
• Acute physiology and chronic health evaluation
• Predicts outcomes in ICU patients as a group but
  should be used to predict individual outcome
• Looks at primary disease process as well as 12
  different physiological variables (eg-HR, BP, RR,
  WBC) then predicts mortality
• Units can compare themselves to other ICUs and
  see if their mortality rate is similar for a
  diagnostic group
• SAPS
• Simplified acute physiology score
• Similar to the Apache II

12
Scoring Systems, cont

• Pathology-Specific scoring systems
• Trauma Score (TS)
• RR, resp effort, systolic BP, cap refill, and
  Glascow coma score are integrated to assess
  patient status
• High scores mean the person needs a trauma center
• Abbreviated injury scale
• Correlates injuries with morbidity and mortality

13
Cost of Critical Care

• Most of the ICU cost is labor
• About 40 of spending is on drugs, imaging, lab
  tests, and supplies
• Cost saving usually involves reduction in force
  (fewer staff) which risks reducing the quality of
  care
• Daily basic ICU costs in the UK are 800-1600
  (how many is this?)
• 13 of the gross domestic product in the US is
  spent on healthcare with critical care 7 of the
  total expenditurethe GDP for the 3rd quarter of
  2006 was 13,327.1 billion dollars how much was
  spent on healthcare during this quarter (in
  dollars)?