The Intensive Care Unit
Original Editor - Chidile Muonwe
Intensive care represents the highest level of patient care and treatment designated for critically ill patients with potentially recoverable life-threatening conditions. The Centers for Medicare & Medicaid Services defines critical illness or injury as “acutely impairing one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient’s condition”. Intensive care (critical care) is a multidisciplinary and interprofessional speciality specifically designed for the management of patients at risk of developing or with established, life-threatening organ failure. The capacity to temporarily support and if necessary, replace the function of many failing organ systems, particularly the lungs, cardiovascular system and kidneys, is what underscores intensive care medicine.
The Intensive Care Unit (ICU) is a separate, self-contained area within a medical facility, equipped with high-tech specialised facilities designed for close monitoring, rapid intervention and often extended treatment of patients with acute organ dysfunction. It is committed to the management and continuous monitoring of patients with life-threatening conditions. The aim of intensive care is to maintain vital functions in order to prevent further physiological deterioration, reduce mortality and prevent morbidity in critically ill patients. Provision of intensive care is within the continuum of primary, secondary and tertiary care, with the majority of these services delivered in the secondary-care setting.
Types of Intensive Care Units (ICUs)
Intensive care units can be organised based on the pathologies/conditions treated (e.g. neurological, trauma, burns, medical or surgical ICUs) or by the age group of the patient admitted (adult or paediatric). Specialized intensive care units include medical, surgical, pediatric and neonatal intensive care units.
Medical intensive care unit
The medical intensive care unit is dedicated to the care of adult patients with medical conditions requiring frequent observation, specialized monitoring and medical treatment. These include illnesses such as diabetic ketoacidosis, gastrointestinal bleeding, drug overdose, respiratory failure, sepsis, stroke and cancer.
Surgical intensive care unit
The surgical intensive care unit is dedicated to the management of postoperative patients, including postoperative patients who have undergone major abdominal surgeries, craniotomy patients, thoracotomy patients, unstable multiple trauma patients and any surgical patient who requires continuous monitoring or life support.
Pediatric intensive care unit
Critically ill children are managed in the paediatric intensive care unit. Children who had just undergone surgery and are at risk of deterioration are also managed in the pediatric intensive care unit.
Neonatal intensive care unit
The neonatal intensive care unit is responsible for the management of premature, high-risk and critically ill infants. Neonates with congenital disorders and birth complications are also managed in the neonatal intensive care unit.
Many other types of ICUs exist, for example, coronary units, burns units, trauma ICUs, mixed ICUs and out-of-hospital ICUs (mobile ICUs).
Equipment in the ICU is mostly aimed at life-support and the support of different organs in the body (for example the lungs, the heart or the kidneys). These include, but is not limited to:
- Cardiac monitors - to monitor vital signs
- Mechanical ventilator
- Infusion pumps - to regulate the flow of medication titrated via a drip and through the infusion pump
- Syringe pumps - where a syringe is used to titrate the medication to the patient
- Suction machines
- Other respiratory support machines such as BiPAP and CPAP
Indications for ICU admission
Intensive care resources are limited and expensive and therefore patients should be carefully selected for admission to ICU. Two patient categories have been identified not to benefit from ICU care, these are described as being "too well to benefit" and "too sick to benefit" from critical care services. The decision to admit a patient in the ICU should be made by the specialist intensivist in agreement with the referring team and it should be based on the severity of the illness, chronic health and physiology reserve, and therapeutic susceptibility as well as being informed by the wishes of patients or caregivers.
Many factors contribute to the triage decisions made for admission into ICU. One classification suggests the factors to be contextual, patient and physician-related. Contextual factors include characteristics of the ICU for example, the current availability of beds, appropriate equipment and expertise of the nursing staff. Patient factors refer to the characteristics of the patient such as their preferences, functional capacity, age and comorbidities, as well as the characteristics of the illness with regards to severity, reversibility, responsiveness to therapy and quality of life after discharge from ICU. Physician factors refer to the characteristics of the person making the decision which include experience, personality, mood and biases.
Even though admission criteria may vary between ICUs and from country to country, universal criteria have been recommended for patient admission into the ICU. Following their prioritization model, the Society of Critical Care Medicine (SCCM) categorised patients into four priority level groups in their guidelines for ICU triage. These groups are based on how likely the patients are to benefit from admission to the ICU and can be found in the table below:
The SCCM also provided some diagnoses and parameters for ICU admission in their previous guidelines for ICU admission, based on their diagnosis and the objective parameters models. A list of these has been provided in the table below. Currently, there is however no conclusive evidence informing ICU admission criteria.
|Drug Ingestion and Drug Overdose||
Table 2: Indication for ICU admission. Adopted from the European Critical Care Society Guideline for ICU admission.
Why Commence Physiotherapy Early in the ICU?
Physiotherapy is one of the principal and most consistent therapy services for Critical Care. Physiotherapists (PTs) carry out individualized assessments of patients admitted to the ICU to identify the needs of each patient.
The risk for muscle weakness, delirium and prolonged mechanical ventilation is increased in ICU patients because of their physical inactivity. These complications can eventually lead to physical and cognitive impairments which could last for years after discharge from the ICU. PTs play a vital role in the prevention and management of respiratory disorders as well as the prevention and management of musculoskeletal and neuromuscular disorders in both intubated and spontaneously breathing patients in the ICU.
Early mobilisation and physical rehabilitation are considered paramount to the recovery of critically ill patients in ICU. Evidence exists that it is safe and at low risk for adverse events and that it:
- Improves physical functioning
- Decreases ICU acquired weakness
- Decreases the duration of mechanical ventilation
- Decreases the length of stay in ICU
Early physiotherapy for patients in the ICU is also necessary to mitigate other complications that might arise such as ICU delirium, ventilator-associated pneumonia and ICU acquired neuropathy/myopathies among others.
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