CRITICAL CARE MEDICINE- AN INTRODUCTION Dr Samir Sahu Bhubaneswar.

What is Intensive Care an intensive care unit as “a hospital area in which an increased concentration of specially trained staff and monitoring equipment allow more detailed and frequent monitoring and more frequent intervention in seriously ill patients” to include all medical activities performed in any place where there is a seriously ill patient, including emergency departments, ambulance services, disaster zones, etc.

intensivists must be managers, economists, and also have a regular ongoing commitment to the unit,

What is Critical Care Medicine? Critical care medicine is the multidisciplinary healthcare specialty that cares for patients with acute, life-threatening illness or injury (SCCM definition). Critical care (medicine) is maturing into a separate specialty whose practitioners are “intensivists” and whose practice is moving from consult based “open” units, to multidisciplinary “closed” units.

Critical Care Medicine is a term used in the North America to describe the practice of medicine in intensive care units (ICU). Elsewhere it is known as Intensive Care Medicine (ICM); in Great Britain, ICUs are often referred to Intensive Therapy Units (ITU). A specialist who practices intensive care medicine is known as an intensivist, and has usually been trained and board certified in anesthesiology, surgery, internal medicine or pediatrics.

Critical Care Medicine is a relatively modern specialty; the first intensive care units opened in Europe in the late 1950s and rapidly spread to North America. Certification of training in this field did not occur in the United States until By the late 1990s, there were approximately 5000 intensive care units in the USA. For many years intensive care was something of a “free for all” struggle between various interest groups, with the patient often caught in the middle. This arose from the mistaken view of many physicians that intensive care patients were merely sicker versions of the patients that they already looked after on the wards.

An open ICU model evolved, with the primary physician making the decisions and a support team of specialists acting as consultants. It has since been shown that the presence of a properly trained intensive care physician in the unit significantly reduces morbidity, mortality and cost.

There is an emerging body of evidence that “closing” units (the intensive care team look after all aspects of patient care, the primary team consult) may further improve outcomes and cost effectiveness. Critical care, as a specialty, has matured, and with the prevalence of cost containment as the major driving force in healthcare, the intensivist is becoming an essential component in cost control, and quality assurance strategies.

Critical Care Delivery in Intensive Care Units in India: Defining the Functions, Roles and Responsibilities of a Consultant intensivist Recommendations of the Indian Society of Critical Care Medicine Committee on Defining the Functions, Roles and Responsibilities of a Consultant intensivist Divatia JV, Baronia AK, Bhagwati A, Chawla R, Iyer S, Jani CK, Joad S, Kamat V, Kapadia F, Mehta Y, Myatra, Nagarkar S, Nayyar V, Padhy S, Rajagopalan R, Ramakrishnan N, Ray B, Sahu S (Bhubaneshwar), Sampath S, Todi S. Indian Journal of Critical Care Medicine, Year 2006.

Three factors differentiate intensive care from other wards in hospitals: 1) a very high nurse to patient ratio, 2) the availability of invasive monitoring, 3) the use of mechanical and pharmacological life sustaining therapies (mechanical ventilation, vasopressors, continuous dialysis).

What is Critical Illness? Critical illness is a condition where life cannot be sustained without invasive therapeutic interventions. A wide variety of diseases may lead to critical illness; however the number of interventions required is limited. A high ratio of nurses to patients is characteristic of intensive care units.

Many doctors and nurses have a very poor understanding of what constitutes an intensive care patient: they are not merely standard medical or surgical patients, sicker than normal, perhaps plugged into ventilators. All intensive care patients fit into one of the following categories

The Coronary Care model Patients admitted to intensive care for intensive monitoring, in anticipation of possible aggressive interventions: this is the coronary care model.

Post operative cardiac care Patients admitted to units which act as extensions of the post-operative recovery room, allowing abnormal perioperative physiology to reverse, with or without modulation of the normal stress response. Post operative cardiac care is an example of this model.

Burns Unit Patients who require very intense nursing care, which would not be available elsewhere: an example of this is a burns unit.

Neurosurgical Critical Care Patients who do not necessarily require life sustaining treatments, but whose physiology is taken under control in order to prevent organ injury: neurosurgical critical care.

Medical Intensive Care Patients who have minimal physiologic reserve, and who undergo acute potentially reversible injury, requiring life support until the abnormalities have been reversed and reserve restored: this is the archetypical medical intensive care patient (COPD with pneumonia requiring mechanical ventilation).

Surgical Intensive Care Units Patients who undergo an massive disruption to their physiology, due to an overwhelming stress response to injury, or inadequate compensation to the response: this is the patient frequently seen in surgical intensive care units – major trauma or sepsis such as pancreatitis

In many cases the course of illness is prolonged, and the underlying causes difficult to discern. Indeed there appears to be great interpatient variability – two patients with the exact same injury may follow different paths: one may follow the standard stress response - acute compensation, followed by hypermetabolism and catabolism and, after 4 to 7 days, resolution with fluid mobilization and anabolism. The second patient may rapidly develop multi organ failure and remain in intensive care for a prolonged period of time

Teamwork, Care, Compassion & Organization The intensive care unit is not merely a room or series of room filled with patients attached to interventional technology, it is the home of an organization: the intensive care team. This team – doctors, nurses, therapists, nutritionists, chaplains and other support staff, builds an environment for healing or dying. Each member brings different skills to the table - compassion is the common element. Critical Care is about medicine, care, compassion and organization. The best intensive care units are the ones with the most effective management structures.

Patients are admitted to intensive care, for the most part, with one or more of the following problems: hemodynamic insufficiency, respiratory failure, abnormalities of fluid and electrolytes, Sepsis, coma.

Seven Cs of critical care: Compassion Communication (with patient and family). Consideration (to patients, relatives and colleagues) and avoidance of Conflict. Comfort: prevention of suffering Carefulness (avoidance of injury) Consistency Closure (ethics and withdrawal of care).

Role of Intensivist Clinical expertise Care directed & coordinated by committed specialists Facilitate communication & coordination Provide effective & informed management of Admissions & Discharges Offer valuable insights into difficult ethical decisions

What is Critical Care Care of seriously ill patients with Life threatening illness & trauma or have potential to develop Life threatening complications

Is there a need for Critical Care Unit ? YES. There is unequivocal evidence that Critical Care Units result in decrease in Mortality & Morbidity in certain types of patients

Which Patients should be admitted to a Critical Care Unit ? Patients who need high level of medical & nursing supervision. Patients who need high level of interventions Patients who have a reversible pathology Patients who have a reasonable prospect of recovery

Requirement of ICU Teamwork & Multidisciplinary approach A designated consultant available 24hrs 24hrs dedicated Resident cover Ability to support organ system failure (ventilatory, circulatory, renal etc.) Appropriate monitoring & other equipments Resuscitation Transport Continuing medical education & training

Technological Capacity of ICU Cardio-Pulmonary Resuscitation Airway management & Ventilation Oxygen delivery system & therapy Continuous Electrocardiographic monitoring Emergency Temporary Cardiac Pacing Rapid & comprehensive Lab services Radiology Nutrition Titrated Therapeutic interventions Qualified Biomedical personnel Portable life support equipment for transport

Improvements Required Sufficient number of trained nurses Written summary of treatment plan for each day is developed during morning rounds & posted at the bedside for all the members of the critical care team Protocolized delivery of MV, sedation etc Early involvement of intensive care personnel in evaluation & treatment outside the ICU to avoid delay in care of patients with organ dysfunction Process optimization needs great leadership, administrative, communication & organizational skills Quality control & continuous process improvement must be integrated in daily practice of intensive care

Levels of ICU Level 1 - Immediate resuscitation - Short term Cardio-Respiratory support & monitoring Level 2 - Between 1 & 3 Level ventilated ICU beds, 300 ventilations/yr - Complex multi-system life support for indefinite period - 1:1 nursing for ventilated patients Level 0- (HDU)Noninvasive monitoring only (Intermediate Care) Proposed Guidelines for ICU`s in INDIA

High Dependency Units Monitoring Single organ failures Immediate resuscitation Short-term respiratory support Step down for ICU patients More comfortable for conscious & alert pt 1:3/1:4 nursing Reduces cardiac arrests in ward & ICU readmissions

Patient Care Multidisciplinary (medical, nursing, others) Critical care nurse is the primary carer Formal ward round by multidisciplinary team twice daily Assess clinically, path, radiology & other investigations, medication charts reviewed, progress determined & management plan developed. Unstable patients require more frequent assessment & intervention

Procedure Skills in ICU Arrhythmia detection & treatment Providing Cardioversion & CPR Inserting Endotracheal tubes Managing Ventilation Placing & maintaining Central & Arterial lines

Procedures Intubations1600 Central Lines 773 Tracheostomy 120 Ventilations 1506

Other Clinical Activities Care of Family Outreach

Quality Improvement Promote a culture of Quality Improvement Documented formal audit Review of processes & outcomes Processes – clinical audit (mortality, morbidity, delayed transfer), compliance with protocols, guidelines & checklists, critical incident reporting Outcome – SMR, CRBSI, patient & relative satisfaction etc.)

Complications VAP rate Adverse Events

INTENSIVIST - Who? PG in Medicine, Anaesthesia, Chest Med. Surgery, Orthopaedics & 3-5yrs experience (>50% time spent) in Level 2-3 ICU & or IDCC/IFCC(ISCCM), DNB in Critical Care + 2-3yrs experience Proposed Guidelines for ICU`s in INDIA

Critical Care Courses Fellowship in Certificate Care Medicine – Critical Care Education Foundation – post MBBS (3yrs) – (12 centres) IDCC (Indian Diploma in Critical Care) - ISCCM - Post PG(1yr) – (57 centres) IFCC (Indian Fellowship in Critical Care) – ISCCM – Post PG (2yrs)-(20 centres) DNB - Post PG (2yrs) – (17 centres)

OPEN vs CLOSED ICU Semi-Open ideal for us at present - Primary Physician continues care - Intensivist looks after Ventilation, Nutrition, Infection control, Haemodynamic monitoring - Other Consultants called in to manage specific areas

Operational Policies Admission Discharge Refferal Lines of responsibility delineated & job descriptions defined Patient care policies formulated & standardised (infection control, transport, end-of-life, sedation etc)

ICU Structure & Size One Large Multispeciality Unit OR Multiple Small Sub-speciality ICUs 1-4% of Hospital beds Minimum 4 & maximum 26 beds Ideally 4-12 beds

Types of Cases (17355) Cardiology - 20% Angios - 19% Respiratory - 6% Neurology - 8% Cardiothoracic - 6% Neurosurgery - 14% Infections - 11% Multitrauma - 1.5% Post - op - 4% Poisoning Gastrointestinal – 3 Renal - 4 Metabolic - 1 Miscellaneous - 2%

Indication for Admission(99-08) LVF/CCF Conduction Defect – 460 Arrhythmia Shock Respiratory Failure –1941 Neurocritical Care Metabolic Emergencies – 100 Renal Failure Monitoring

No. of Cases – 2005 (2119) Angios – 456 CAD Neuro Surg – 169 Post-OP Head Injury – 112 Sepsis CVA - 81 Malaria - 70 Multitrauma – 68 LVF - 66 Heart Block - 63 COPD - 58 ARDS - 34

No. of Cases – 2006 (2050) Angios – 337 CAD Neuro Surg – 113 Post-OP Head Injury – 133 Sepsis CVA - 91 Malaria - 95 Multitrauma – 20 LVF - 67 Heart Block - 67 COPD - 75 ARDS - 36

No. of Cases – 2007(2112) Angios – 229 CAD Neuro Surg – 85 Post-OP Head Injury – 178 Sepsis CVA Malaria - 54 Multitrauma – 39 LVF - 84 Heart Block - 90 COPD - 75 ARDS - 25

No. of Cases – 2008(1842) Angios – 170 CAD Neuro Surg – 102 Post-OP - 62 Head Injury – 183 Sepsis CVA Malaria - 91 Multitrauma – 33 LVF - 81 Heart Block - 67 COPD - 69 ARDS - 19

No. of Cases – 2009(2056) Angios – 210 CAD Neuro Surg – 126 Post-OP Head Injury – 172 Sepsis CVA Malaria - 79 Multitrauma – 46 LVF - 59 Heart Block - 51 COPD - 84 ARDS - 20

Types of cases-KHL

Intensive Care will have an increasing important role as the general population ages & expectation of Healthcare & complexities of Surgery increases