1. An Introduction to Intensive Care Medicine
Dr. Sam Bampoe
University College London Hospitals

2. Overview What can we do? Who do we admit?
Basic concepts of critical care
Clinical context

3. Critical Care Medicine

4. What do we do on ICU? Haemofilter Vital signs monitor
Intravenous sedation
Nasogastric feed
Intravenous fluid pump
Cardiac output monitor

5. What do we do on ICU? “
Maintain normal physiology using pharmacology and technology, whilst treating pathology…...
I would like to begin by asking you to consider your answer to the following question: how do you secure your epidural catheters in labour? And perhaps after this talk, ask the person sitting next to you how they secure theirs; it is likely that their method will differ from yours.
The consequences of unintentional epidural catheter migration are well documented - including failure of analgesia, an increased likelihood of resite and the incumbent risks which that carries, and of course a negative impact on patient experience. It is therefore perhaps a little surprising that no evidence based gold standard method of catheter fixation method exists. This may, in part, explain the wide variation in practice observed.

6. What do we do on ICU? Stabilise and treat
Advanced and invasive monitoring
Organ system support
Neurological
Cardiovascular
Respiratory
Renal
Gastrointestinal and hepatic
All of the above!

7. Who do we admit? Routine admissions
High risk elective surgical patients
Enhanced recovery after major surgery
High risk emergency surgical patients
NELA
NCEPOD
RCS

8. Who do we admit? Emergency admissions
“ Critically unwell patients with a potentially reversible cause for their illness”
Respiratory failure
Sepsis
Trauma
Renal failure
Post cardiac arrest

9. Helen 63 years old 2 week history of cough Mild/moderate COPD
Productive of green sputum
Mild/moderate COPD
Type 2 diabetes mellitus
Hypertension
CKD

10. On examination HR 103 BP 117/72 Warm peripheries
RR 28 O2 Stats 87% on 2L oxygen
Coarse crepitations in right lower zone with bronchial breathing in right mid-zone

11. Investigations

12. Respiratory Failure Type 1 Type 2 Failure of oxygenation Low PaO2
Low or normal PaCO2
Type 2
Failure of ventilation (+/- oxygenation)
Low or normal PaO2
High PaCO2

13. What should we do with this patient?
Oxygen!
Antibiotics
Fluids
Chest physio
Where should we care for this patient?

14. Levels of care Primary vs secondary care Outpatient vs inpatient care

15. Levels of care Level 0 Level 1 Level 2 Level 3
Requires hospital admission - ward based care
Level 1
Requiring additional monitoring, clinical input or advice (outreach)
Recently discharged from ICU
Level 2
Requiring single organ monitoring and support
Requiring advanced monitoring
Level 3
Requiring advanced organ support
Two or more organ system failures

16. Admitted to medical HDU (level 1 care)
High flow 02 – 15L
Antibiotics
Chest physio
Nebulisers
O2 SATs remain 89%
RR now 40
Referred to ICU

17. What can we do to help? “Admit, stabilise and treat”
Advanced monitoring
arterial line
Organ support
Non invasive ventilation (NIV)
1:1 nursing
Doctor always present

18. Non-invasive ventialtion
Continuous positive airway pressure (CPAP)
Alveolar splinting
Improves oxygenation
Bi Level positive airway pressure (BiPAP)
Improves tidal volume
Improves ventilation (and oxygenation)

19. 24 hours later…...... 80% oxygen PaO2 7.7Kpa PaCO2 6.1Kpa RR 40
Patient feels exhausted and drowsy
What now?

20. Invasive ventilation Indications Life threatening hypoxaemia
Failure of NIV
Depressed conscious level GCS < 8
Airway protection eg. Burns
Severe dyspnoea

24. Back to ICU…... Inspired oxygen now 50% O2 sats 90% Pa02 8.7 HR 125
BP 77/47
T38.9

25. SEPSIS
150,000 cases per year
44,000 deaths

26. Sepsis kills!

27. The Sepsis Six Oxygen Blood cultures Antibiotics Fluids Lactate
7.6% increase in mortality for every hour delay in giving antibiotics
Oxygen
Blood cultures
Antibiotics
Fluids
Lactate
Urinary catheter

28. Septic Shock

29. Cardiovascular physiology
BP = CO x TPR
CO = SV x HR
BP = (SV x HR) x SVR
We can measure these values using cardiac output monitoring

30. Managing refractory hypotension
BP = (SV x HR) x SVR
Low SV
fluids
Low SVR
vasopressors
Low CO (despite fluids)
inotropes

31. Cardiovascular support
Inotropes vs vasopressors
Noradrenaline
Adrenaline
Dobutamine
Calcium
BP = (SV x HR) x SVR

33. Central Access

34. Noradrenaline complications
Profound capillary vasoconstriction
End-organ hypoperfusion
Ischaemic injury
Arrhythmias

35. Helen Intubated 50% oxygen requirement On Noradrenaline
Cr 267 (170 baseline)
Ur 17
UO 15ml/hr

36. Acute Kidney Injury Pre-renal Intrinsic Post-renal
Hypovolaemia, hypotension, excessive vasoconstriction (vasopressors)
Intrinsic
Acute tubular necrosis (eg drugs), glomerulonephritis, rhabdomyolysis
Post-renal
Renal calculi
Blocked catheter
Neuropathic bladder

37. Helen
Cr 450
K+ 5.1
Urine output 6ml/hr

38. Renal replacement therapy

39. Renal replacement therapy
Indications
Symptomatic uraemia
Cr > 600
Hyperkalamia
Acidosis (endogenous vs exogenous)
Significant Oliguria/anuria
Fluid management

40. Helen Respiratory failure Cardiovascular failure Renal failure
Multi-organ failure

41. How long will Helen stay on ICU?

42. What about life after ICU?

43. Life after ICU…. 50% of patients who survive suffer psychological harm
Clinical depression
Anxiety
PTSD
ICU follow up clinics now increasingly common

44. Summary Basic principles of ICU Who we admit What we can do
What happens to our patients
Life after ICU

45. Questions?