Introduction, Introduction, function of ICUfunction of ICU

Lorx András

• AOANEANE_1A• Intensive Therapy and

Anaesthesiology

• “Compulsory”

• Credit: 2• Lectures, practices

• Exam: MCQ test (from the 2nd oral possible)

• AOVANE104_1A• Anaesthesiology and

Intensive Therapy

• “Elective”

• Credit: 2• Lectures: regular

attendance is required (max. 3 absence)

• Exam: MCQ test

• The place of ICU

KKúútvtvöölgyi lgyi VVáárosmajorrosmajor

„„Baleseti KBaleseti Köözpontzpont””

AEKAEK

The targetThe target

• To have a general insight into the everyday's of an ICU

• The approach of a critically ill patient, assessment, basics of therapy

• Equipments

• Anaesthesia, perioperative management

Your website:Your website:

• www.intenziv.sote.hu/english

• It is compatible with Internet Explorer

NEPTUN NEPTUN –– groups groups -- lectureslectures

• Max. 10 students in a group• Group assignments strictly according to the

NEPTUN• Changes between groups just through the

NEPTUN

PracticesPracticesVersion 4.0 INTENSIVE THERAPY AND ANAESTHESIOLOGY 2010/11/1 semester

IX. 6-10. IX. 13-17. IX. 20-24. IX. 27 - X.1. X. 4-8. X. 11-15. X.18-22. X. 25-29. XI. 1-5.Group/Week 1. 2. 3. 4. 5. 6. 7. 8. 9.

Monday 10:40-12:10 EM-16 BEV-Kut GiVEn-Kut Card-IA-Major

8:30 - 10:00

W ednesday

EM-1 BEV-Kut GiVEn-Kut Card-IA-Major Resp-Int-Kut Traum-IA-BK Ane-KutEM-2 BEV-Kut GiVEn-Kut Card-IA-Major Resp-Int-Kut Traum-IA-BKEM-3 BEV-Kut GiVEn-Kut Card-IA-Major Resp-Int-Kut Traum-IA-BKEM-4 BEV-Kut Card-IA-Major Resp-Int-Kut Traum-IA-BKEM-5 BEV-Kut GiVEn-Kut Card-IA-Major Resp-Int-Kut

Friday12:30 - 1

4 :00

8:30 - 10:00

W ednesday

EM-6 BEV-Kut GiVEn-Kut Card-IA-Major Resp-Int-Kut Traum-IA-BKEM-7 BEV-Kut GiVEn-Kut Card-IA-Major Resp-Int-Kut Traum-IA-BKEM-8 BEV-Kut Card-IA-Major Resp-Int-Kut Traum-IA-HkEM-9 BEV-Kut GiVEn-Kut Card-IA-Major Resp-Int-Kut

EM-15 BEV-Kut GiVEn-Kut HiFi-Sim-Kut

Friday12:30 - 1

4 :00

Friday14:15 - 1

5 :45

EM-10 BEV-Kut GiVEn-Kut Card-IA-Major Resp-Int-Kut Traum-IA-HkEM-11 BEV-Kut GiVEn-Kut Card-IA-Major Resp-Int-Kut Traum-IA-HkEM-12 BEV-Kut Card-IA-Major Resp-Int-Kut Traum-IA-HkEM-13 BEV-Kut GiVEn-Kut Card-IA-Major Resp-Int-KutEM-14 BEV-Kut GiVEn-Kut HiFi-Sim-Kut

Intensive therapy and Anaesthesiology - T y p e s o f P r a c t i c e s Intensive therapy and anaesthesiology - P l a c e s o f P r BEV-Kut Introduction - Equipments - Examination Kútvölgyi Kut SE KútvölgyiClinical Center

GiVEn-Kut Pancreatitis, GIH, kidney, liver, endocrin Kútvölgyi Major SE Városmajor Clinical CenterCard-IA-Major Cardiovascular intensive therapy Major BK Baleseti Központ Trauma Center 7th floor ICUResp-Int-Kut Respiratory failure and ventilation Kútvölgyi Hk Honvédkórház - Állami Egészségügyi Központ Military HospitalTraum-IA-BK Traumatologic intensive therapy and anaesthesia Baleseti KözpontTraum-IA-Hk Traumatologic intensive therapy and anaesthesia Honvédkórház

Ane-Kut Anaesthesiology KútvölgyiHiFiSim-Kut High-Fidelity Simulation Kútvölgyi

Friday14:15 - 1

5 :45

PracticesPractices

• Attendance is mandatory (max. 2 absence)

• Signatures collected in all practices

• Attendance is accepted according to the schedule and Neptun group assignment

Economic Impact of ICUEconomic Impact of ICU

• <10% of hospital beds• 30% of acute care hospital cost• >20% of hospital budget• 1% of GNP expended for ICU care

• With aging of the population• Demand for critical care service will

increase

ICUICU• So expensive

per patientper time interval

We need data about the type and qualityprovided in ICU

ICU Model CareICU Model Care• Full-time intensivist model :

– patient care is provided by an intensivist• Consultant intensivist model :

– an intensivist consults for another physician to coordinate or assist in critical care, but dose not have primary responsibility for care

• Multiple consultant model:– multiple specialists are involved in the patient care,

(esp. R/T doctors for ventilators), but none is designated especially as the consultant intensivist

• Single physician model :– primary physician provides all ICU care

Open UnitsOpen UnitsDefinition :

any attending physician with hospital admitting privileges can be the physician of record and direct ICU care. (All other physicians are consultants)

Disadvantage :• lack of a cohesive plan• Inconsistent night coverage• Duplication of services

Closed UnitsClosed Units• Definition:

An intensivist is the physician of record for ICU patients. (other physicians are consultants), All orders & procedures carried out by ICU staff

• advantage:• improved efficiency• standardized protocol for care

• disadvantage:• potential to lock out private physician • increase physician conflict

Transitional UnitsTransitional Units

Definition:intensives are locally present shared co-

managed care between ICU staff and private physicianICU staff is a final common pathway for orders

and proceduresAdvantage:

reduce physician conflict, standard policies and procedures usually present

Disadvantage:confusion and conflict regarding final authority & responsibilities for patient care decision

Advantages of IntensivistsAdvantages of Intensivists

• Morbidity (ICU, 30-day, hospital) • Cost • Length of stay (ICU, hospital)• Complication

A Good ICUA Good ICU• Well organized

trustcoordinated care

• Full-time intensivist: daily round• protocol & policies (eg: how to DC elective

operation when bed not available)• bedside nurses (master degree)• no intern

A Good ICUA Good ICU

• A team:doctors, nurses, R/T, pharmacists

• led by full time intensivistscritical care trainedavailable in a timely fashion (24hr/day)no competiting clinical responsibilitiesduring duty

• closed units, if resources allow

Role and function of ICURole and function of ICU

Roles of ICU: (MNT) Level I Level II Level III HDU ICU

Intensive Monitoring

Intensive Nursing

Intensive Therapy

Intensive therapy/Critical care medicine:Intensive therapy/Critical care medicine:

• temporary support or replacement offunctionally disturbed or failing vital functionslike:– Respiration– Circulation– Metabolism– Temperature– &– therapy of the underlying diseases at the same time

Main admission indications:Main admission indications:• Major surgery• Acute respiratory failure• Acute circulatory failure• Acute renal failure• Acute hepatic failure• Acute metabolic/endocrine

failures• Shock-states• Intoxications• Tetanus

•

• Hemostatic failure• Fluid-electrolyte, acid-base

disturbances•

Postoperative complications• Multiple trauma/Polytrauma• Burns• Coma• Eclampsia• Post-resuscitation period

Gastrointestinal Bleeding

OrganisationalOrganisational considerations:considerations:

• Classification:

Single-discipline ICU (surgical ICU, medical ICU, CCU, burn unit, etc.)General multidisciplinary ICUPediatric and neonatal ICU

Postoperative high dependency unit

OrganisationalOrganisational aspects:aspects:• 1. What type?• General multidisciplinary ICU is more cost-effective than single-

discipline ICU • Critically ill have the same pathophysiological processes regardless of

the primary disease, and they require the same approaches to support vital organs. For example single-discipline doctors lack the experience and expertise to deal with the complexities of MODS/MOF.

• 2. How large?• The number of ICU beds usually ranges from 1-4 / 100 total hospital

beds.• ICU beds < 4 is resource consuming; ICU beds > 20 hard to manage• 3. Where ?• Possible limitation of the movement of critically ill (Op. theatre, ER, CT,

etc.)

Level of CareLevel of Care and and Resuscitation Measures Policy Resuscitation Measures Policy

Level 1: Maximal interventions (including CPR, ICU)

Level 2: Maximal interventions with some restrictions to resuscitative measures

Level 3: Maximal interventions on the ward; no CPR; no transfer to an ICU.

Level 4: Interventions aim to treat easily reversible conditions, maintenance of function and comfort care. No CPR, No ICU.

Level 5: Interventions adapted to end of life. No CPR, No ICU, Focus on symptom relief.

The form must be signed by the physician. The signature of the The form must be signed by the physician. The signature of the patient or surrogate involved in the planning of care is optionapatient or surrogate involved in the planning of care is optional.l.