[Intensive care] Introduction

Intensive care physicians manage patients with diseases or injuries which threaten to cause organ dysfunction or death. Often the patients present with organ dysfunction. These patients are monitored and supported by relatively invasive equipment. Sedation and anaesthesia are often necessary.
There is significant overlap with anaesthesiology. 

 

Etymology

In the UK and English speaking countries, intensive care patients are managed in an intensive care unit (ICU). This can also be called an intensive therapy unit or intensive treatment unit (ITU), or a Critical care unit (CCU).

Abroad the ICU may be called:

• Unidad de cuidados intensivos (UCI) (Spain)
• Unidade de terapia intensiva (UTI) (Portugal)
• Unité de soins intensifs (USI) (France)
• Terapia Intensiva (Italy)
• Intensivstation (ITS) (Germany)
• Intensiv afdeling or intensivafsnit (ITA) (Denmark)
• Intensivavdeling  (ITA) (Norway)
• Intensivvårdsavdelning (IVA) (Sweden)
• Отделение реанимации и интенсивной терапии (ОРИТ) (Russia)

Specialists in this field are often called intensivists. (Compare to internist: internal medicine).

 

Sub-specialties

• Paediatric intensive care
• Neonatology / neonatal intensive care

 

History

In 1853, during the Crimean war, Florence Nightingale, began the practice of intensive monitoring of critically ill patients. She is often called the founder of modern nursing, 
In 1953, a Danish anaesthethist, Bjørn Aage Ibsen established the first intensive care unit in Kommunehospitalet (The Municipal Hospital) in Copenhagen.

 

The scope

• ICU beds are intended for patients who are likely to benefit long term. Many patients who are likely to die will not benefit from intensive care.
• Patients must be likely to be able to leave the ICU after their recovery (within days, weeks or months). It is inappropriate to admit patients who are likely to be kept alive in ICU, but unlikely to ever again survive without intensive care. This would necessitate the ICU doctors eventually ending life-prolonging treatment to spare the resources for new patients.
• Patients should be stepped down from ICU to HDU (high-dependency units) or equivalent, as soon as it is safe to do so. HDUs can step these patients back up to ICU if they deteriorate.

 

Responsibilities

• Monitoring of patient's vital signs
• Management of blood pressure and fluid balance
• Management of heart rate 
• Management of pain in conscious patients  
• Application of local anaesthesia 
• Induction of general anaesthesia 
• Adjustment of neuromuscular blockade 
• Airway management  
• Intubation  

Anaesthesiologists learn these skills so that they can manage patients during operations. This gives them useful preparation for managing patients in an intensive care unit.
However, in the UK, physicians from many medical specialties can enter the intensive care training pathways.

 

History taking  

This is challenging as many patients are either too ill to speak, or too confused to communicate effectively with doctors. Often there is damage or swelling in the airways, or a medical device sitting in the airway.

A medical history can be pieced together from relatives, carers, witnesses, other medical professionals, and previous medical/surgical history.

 

Physical examination

Usually a patient entering ICU has already undergone extensive physical examination by other specialties. Furthermore, there are usually invasive medical devices placed into ICU patients which provide a wealth of information on the biomedical status of the patient.

The examinations necessary for intensive care patients can include:

• Cardiac examination
• Respiratory examination
• Abdominal examination
• Neurological examination

However, the examinations performed are rarely so formal. The physical examination is often specific to one systemic question, such as:

• What is the cause of shock? Septic? Cardiogenic? Neurogenic?
• Is the patient fluid overloaded? Too dry? 
• Are the lungs and airways clear? Why not? 
• Are the bowels functioning?  
• Are there signs of peritonitis?
• Has the Glasgow Coma Scale (GCS) score changed?

 

Common problems

• Post-operative care 
• Liver transplantation
• Respiratory failure  
• Circulatory shock
• Sepsis
• Hypovolaemic
• Anaphylactic
• Cardiogenic 
• Neurogenic
• Acute liver failure
• Chronic liver disease (end-stage) 
• Acute respiratory distress syndrome (ARDS)
• Multiple organ dysfunction syndrome (MODS)
• Acute severe asthma 
• Atelectasis 
• Traumatic injury 
• Burns

 

Diseases:

• Chronic-obstructive pulmonary disease (end-stage)  
• Asthma   
• Abdominal aortic aneurysm
• Cirrhosis 
• Influenza
• Parainfluenza
• Acute pancreatitis
• Cervical spinal cord injury
• Tetraplegia
• Guillain–Barré syndrome
• Status epilepticus 
• Botulism