basic tips for beginners on ICU rotations.

1. Basics of ICU care
Dr Guvera Vasireddy

2. What is critical care?
•Critical care is medical care for patients
whose illness requires close, constant
watch by a team of specially trained
caregivers.
•Most critical care takes place in an
intensive care unit (ICU) or a trauma
centre.

3. How does it differ from other branches of
medicine? (Wikipedia)
• Intensive care usually takes a system by system approach to treatment,
rather than the SOAP (subjective, objective, analysis, plan) approach of
high dependency care.
• The nine key systems are each considered on an observation-intervention-impression
basis to produce a daily plan.
• Intensive care treatment raises other issues including psychological health,
pressure points, mobilisation and physiotherapy, and secondary infections.
• The nine key IC systems are (alphabetically): cardiovascular system, central
nervous system, endocrine system, gastro-intestinal tract (and nutritional
condition), hematology, microbiology (including sepsis status), peripheries
(and skin), renal (and metabolic), respiratory system.

4. Many disciplines, one team.
• The concept of critical care is to ensure the survival of the patient and
prevent end organ damage by providing optimal support.
• It involves the institution of set interventions based on evidence
based medicine to improve the survival of critically ill patients with
minimal disability.
• Critical care givers comprise a team care givers with special training.
• Each member of the team has specific role in the care giving and
includes a check list to monitor at each level.

5. Who needs to be admitted to ICU
• Depending on the severity of illness patient care is devided in to three
levels.
• Level 1 – basic care with intermittent monitoring.
• Level 2 – continuous monitoring with ability to provide hemodynamic
support and invasive monitoring.
• Level 3 – invasive ventilator support along with level 2 care.
• Level 2 and level 3 care areas are combined in most hospitals with
lower resources and called as ICUs.

6. How to recognize the severity of illness?
• Back to basics
• assess:
1. Consciousness
2. Airway competency
3. Features of respiratory insufficiency
4. Hemodynamic stability

7. What to do?
• Early goal directed therapies to counter the deleterious effects of loss
of homeostasis.
• Try to bring back the physiological parameters as close to their normal
levels as possible.

8. Intensive care bundles
• A bundle is a structured way of improving the processes of care and
patient outcomes:
• Small, straightforward set of evidence-based practices.
• Generally three to five — that, when performed collectively and
reliably, have been proven to improve patient outcomes

9. Most commonly implemented bundles
1. Ventilator Bundle
2. Central Line Bundle
3. Sepsis Resuscitation Bundle
4. Sepsis Management Bundle

10. Importance of implementation of bundles :
all or none rule
• All the elements of the bundle are necessary and removing any one of
them will result in inferior result.
• All the elements in the bundle are based on randomized controlled trial
(Level 1 evidence) and the recommendations are beyond any controversy.
• A bundle rather focuses on how to deliver this evidence of care rather than
what the right care should be.
• All elements in the bundle involve an all or none phenomenon and the
Bundle itself also bears
Implementation of all Bundle elements should take place
simultaneously at a specific time and place with a minimum delay.

11. Ventilator care bundle
• Elevation of the Head of the Bed
• Daily interruption of sedation and assessment of readiness to wean
• Peptic Ulcer Disease Prophylaxis
• Deep Venous Thrombosis Prophylaxis
• Daily Oral Care with Chlorhexidine

12. What else to do for improving outcomes?
• Daily interruption of sedation protocol
• Coordinate interruption of sedation with weaning protocol
• Use of validated sedation scale
• Incorporate other ICU staff
• Use visual cues
• Standardized order sets
• Checklists / multidisciplinary rounds

13. Central line bundle
• Appropriate hand hygiene
• Chlorhexidine skin prep
• Maximal barriers for central line insertion
• Subclavian vein placement is preferred site
• Review lines daily and remove unnecessary catheters

14. How to implement these bundles?
• Rigorous staff education
• Central line checklist
• Keep all necessary equipment in an easily accessible cart
• Empower nursing to enforce use of a central line checklist
• Include daily review of line as part of multidisciplinary rounds and
daily goals sheet
• Easy to find record of date and time of placement

15. Sedation and analgesia bundle
• Protocol-directed sedation
• Use of validated sedation scale
• Bolus doses of benzodiazepines instead of a continuous infusion
• Sedatives with a short duration of action
• Daily interruption of sedation (DIS) also referred to as spontaneous
awakening trials

16. Sepsis resuscitation bundle
• Describes seven tasks that should begin immediately, but must be
accomplished within the first 6 hours of presentation for patients
with severe sepsis or septic shock.
• Some items may not be completed if the clinical conditions described
in the bundle do not prevail in a particular case, but clinicians should
assess for them.
• The goal is to perform all indicated tasks 100 percent of the time
within the first 6 hours of identification of severe sepsis.

17. Details of sepsis resuscitation bundle
1. Serum lactate measured
2. Blood cultures obtained prior to antibiotic administration
3. Improve time to broad-spectrum antibiotics
4. Treat hypotension and/or elevated lactate with fluids
5. Apply vasopressors for ongoing hypotension
6. Maintain adequate central venous pressure
7. Maintain adequate central venous oxygen saturation

18. Sepsis management bundle
• Lists four management goals.
• Efforts to accomplish these tasks should also begin immediately.
• These items may be completed within 24 hours of presentation for
patients with severe sepsis or septic shock

19. Details of sepsis management details
1. Administer Low-Dose Steroids by a Standard Policy
2. Administer Drotrecogin Alfa (Activated) by a Standard Policy
3. Maintain Adequate Glycemic Control
4. Prevent Excessive Inspiratory Plateau Pressures