The ICU set up

OUTLINE
† DEFINING THE TERMS
† THE HISTORY OF ICU
† THE TYPES OF THE PATIENTS
† INFRASTRUCTURE
† MAN POWER
† BASIS FOR PHYSIOTHERAPY
INTERVENTION
† MORAL & ETHICAL ISSUES
† SCIENTIFIC JUSTIFICATION
What is
† Intensive care?
† close monitoring and constant
medical care of patients with life-
threatening conditions

† ICU care is 24-hour management to

support failing life functions
Intensive care unit?
† An area set aside for the patients who
are critically ill
† A specialized section of a hospital
containing the equipment, medical
and nursing staff, and monitoring
devices necessary to provide
intensive care.
When
† 1950 The ICU’s were established To
meet the increasing demands for more
acute and intensive care required by
patients with complex disorders.
In 1960
• ICU IS A SPEACILITY EVOLVED FROM
THE EXPERIENCE OF RESPIRATORY
AND CARDIAC CARE,PHYSIOLOGICAL
ORGAN SUPPORT IN THE EARLY
1960S
† early ‘70 bedside monitors built
around bouncing balls or conventional
oscilloscope.
† ‘90 Computer-based patient
monitors - Systems with database
functions, report-generation systems,
and some decision-making
capabilities.
Where
† Large medical centers may have more
than one ICU.
NEONATAL INTENSIVE CARE UNIT
† NICU(a newborn
ICU or for the care
of premature and
critically ill infants)

† Incubators, radiant
lamps,
phototherapy
lights,HFOV
Coronary care unit
† A coronary care unit (CCU) is a
hospital ward specialized in the
care of patients with heart
attacks, unstable angina and
various other cardiac conditions
that require continuous
monitoring and treatment.
† Coronary care units developed in the
1960s when it became clear that
close monitoring by specially trained
staff, CPR and medical measures
could reduce the mortality from
complications of cardiovascular
disease
CCU
† The main feature of coronary care is
the availability of telemetry

† This allows early intervention with

medication, cardioversion or
defibrillation, improving the
prognosis
† PICU (Pediatric ICU, dedicated to the
treatment of critically ill children);

† Surgical ICU (SICU, dedicated to the

treatment of postoperative patients).

† MICU (Multidisciplinary ICU)

† High dependency units/ sub acute ICU

ICU design
† Large windowless room
† Eight to 12 beds per unit are
considered best from a functional
viewpoint
† The central nursing station.
† Need for isolation rooms within the
ICU should be considered.
Common conditions
† 8 categories- medical justification for
admission to an ICU.
† Disorders of the cardiac, nervous,
pulmonary, and endocrine (hormonal)
systems, together with post surgical
crises and medication monitoring for
drug ingestion or overdose
Reasons Why patients require
intensive care:
1. Haemodynamic insufficiency
2. Respiratory insufficiency.
3. Deteriorating level of consciousness
or coma.
4. Fluid and electrolyte imbalance
or the anticipation of one of the
above.
How are the patients managed?
† RESTORATION OF SOME DEGREE OF
PHYSIOLOGICAL STABILITY

† PREVENTION OF PRIMARY AND

SECONDARY COMPLICATIONS OF THE
DISEASE
† THE FINAL PRICIPLE OF INTENSIVE
CARE PRACTICE CONCERNS THE
TRANSFER AND REHABILITATION OF
SUCCESFULLY TREATED,
CONVALESCENT PATIENTS
ICU equipment
† Life support and emergency
resuscitative equipment

† Patient monitoring equipment

 What is Patient Monitoring?
“Repeated or continuous
observations or measurements of
the patient, his or her physiological
function, and the function of life
support equipment, for the
purpose of guiding management
decisions”
[Hudson, 1985, p. 630].
Intensive care Unit Bed
ICU Monitoring
† What are we observing?
† Why are we observing it?
† What did we do with the
information?
† What did it change?
† What are the risks to the patient?
† ICU patient monitoring systems are
equipped with alarms that sound
when the patient's vital signs
deteriorate.

† Usually, all patient monitors connect

to a central nurses' station for easy
supervision.
† clinical monitoring gadgets should
complement but not replace an
attentive ICU therapist.
Life saving equipment
† Infusion pumps supply the patient
with fluids intravenously or epidural
through a catheter.
† Crash carts, for immediate availability
when a patient experiences cardio
respiratory failure. The cart holds a
defibrillator, a resuscitator
Manual resuscitator
Defibrillator
Mechanical ventilator
ICU EQUIPMENT
† Central oxygen and suction lines
† Artificial airways
† CPAP/ BiPAP
† Suction apparatus
Specialized equipment
 Effects on patient
“he may cry out for rest,
peace, dignity, but he will
get infusions, transfusions,
a heart machine……he will
get a dozen people around
the clock, all busily
preoccupied with his heart
rate, pulse, secretions or
excretions, but not with
him as a human being”
…kubler-ross 1973
Critical care in India
† Shortage of ICU beds in hospitals

† In most of the time you will find that

the basic facilities and infrastructure
available in many ICUs in no way can
meet the requirement of an ICU

† Shortage of trained manpower

Scope
† Today, one of the major causes of
mortality is road accidents

† In this situation we must accept that

critical care is in demand.
Who are involved in the
treatment?
 MULTIDISCIPLINARY TEAM
† Intensivists (clinicians who specialize
in critical illness care)

† Critical care nurse

† Other attending physicians

Team
† Respiratory therapist

† Physiotherapist

† Pharmacist

† Dietician
ICU staff
† All ICU staff must have undergone
specialized training in the care of
critically ill patients and must be
trained to respond to life-threatening
situations, since ICU patients are in
critical condition and may experience
respiratory or cardiac emergencies.
Patient staff ratio
† Nurse : patient =1:1

† Therapist : patient- ?
Patient care

Although the work of the various

disciplines sometimes overlaps,

each has its own primary focus,

emphasis, and methods of care

delivery.
Is there a role for CPT in the
ICU?

† Yes, BUT….

† Only after careful assessment of

risk:benefit ratio

† Further research is essential

Role of PT
† poorly defined.

† ICU consensus conference in 1983

[1], simply mentioned that they
should be included in the ICU team
and should be involved in any
continuous training programs.
† Consequently, there is little
uniformity in physiotherapy training
or duties, with considerable variation
between, and sometimes within,
countries
What is required?
† Clear defined role?

† After referral or all the cases

why physiotherapy

† Prevention of secondary complications

† Early mobilization and rehabilitation

Post.Op Complications :leading cause of death

Does chest physiotherapy influence

clinical outcomes?
† Airway intubation and mechanical
ventilation impair normal clearance of
tracheobronchial secretions, thereby
increasing the risk of ventilator-
associated pneumonia (VAP).
Early mobilization
† Intensive care is
not just about
organ support
Early mobilization
† Apply state of the art evidence
for integrating exercises physiology,
specifically walking as an intervention in
patients in the ICU

† Early mobilization can facilitate weaning

from mechanical ventilation as well as
enhance functional outcomes by optimizing
cardiopulmonary and neuromuscular status
† Non-Respiratory Aspect Of
Physiotherapy For The Critically
Ill Patient
Morality and Ethics

† Morality
„ The first order beliefs about good and evil by
which we guide our behaviour.
† Ethics
„ The second order reflective considerations of
these moral beliefs and practices
„ Applications of theories and principles to
practical moral problems
Six of the principles commonly
included are:

† Beneficence - a practitioner should

act in the best interest of the patient.

† Non-maleficence - "first, do no harm“

† Autonomy - the patient has the right

to refuse or choose their treatment.
† Justice - concerns the distribution of scarce
health resources, and the decision of who
gets what treatment.
† Dignity - the patient (and the person
treating the patient) have the right to
dignity.
† Truthfulness and honesty - the patient
should not be lied to, and deserves to know
the whole truth about his/her illness and
treatment
To understand
individual actions, we
must also understand
institutional contexts,
since most conflicts
occur in institutional
settings.
What you should know?
have an in-depth knowledge of

† Cardiopulmonary physiology and

pathophysiology
† Patient assessment and cardiopulmonary
diagnostics
† basic life support and critical care
† Pharmacology
&
Skill & experience
Scientific justification
† Evidence-based Practice

- keep up to date with current

research
- involve in the development of
research based practice
What evidence do we have?
† there is only limited evidence
concerning the effectiveness of
physiotherapy in this setting.

† Physiotherapy may have short-term

beneficial effects on pulmonary
function, but it may also adversely
affect the hemodynamic and metabolic
status of intubated patients receiving
mechanical ventilation.
 Proven to be beneficial

† Chest physiotherapy in patients with acute

lobar atelectasis

† Prone position improves oxygenation

(treatment of choice) in some patients with
ARDS

Kathy Stiller, Chest 2000

† side lying improves oxygenation in some
patients with unilateral lung disease.

† pre-oxygenation can decrease or prevent

adverse effects of hypoxemia occurring in
response to suctioning.
 Possibly beneficial

† Multimodality physiotherapy in
patients with hyper secretion,
although the beneficial effects on
respiratory function may be short-
lived.

Kathy Stiller, Chest 2000

 Of unproven benefit

† Routine chest physiotherapy in the

prevention of nosocomial pneumonia.

† Limb exercises to prevent loss of joint

amplitude or soft-tissue length, or
improve muscle strength and
function.
Kathy Stiller, Chest 2000
† There is only limited evidence concerning
which individual physiotherapy techniques are
effective.

† The ability of physiotherapy to facilitate

weaning and to improve function and outcomes
of intubated ICU patients receiving mechanical
ventilation is unknown.

† There is an urgent need for further research to

be conducted to justify the role of
physiotherapy in the ICU.
SUMMARY
† Physiotherapy is an integral part in the
critical care

† Implement protocols to maintain standards

of practice in the intensive care units (ICU).
These represent strategies that have been
derived from evidence-based medicine,
clinical experience and cost saving
techniques
† Critical care in India is at the crossroads of
development.
† The beginning has been made but there is
still a long way to go.
† The field is full of a lot of dynamism,
opportunity and challenges.
† One hopes that all the efforts will lead to a
humane, scientific and meaningful service
for the multitude of critically ill patients.