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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.