The Beginner's Guide to Intensive Care

A Handbook for Junior Doctors and Allied Professionals

Nitin Arora, Shondipon K. Laha, Nitin Arora, Shondipon K. Laha

• Publisher: CRC Press
• Year: 2018
• eBook ISBN: 9781351965651
• Edition: 2
• Topic: Medizin
• Subtopic: Anästhesiologie & Schmerztherapie

'…provides an excellent introduction to the management of acute illness for all clinical staff, and a solid foundation for those who choose to make ICM a fulfilling life-long career.'

From the Foreword by Julian Bion, Professor of Intensive Care Medicine, University of Birmingham

Ideal for any medic or health professional embarking upon an intensive care rotation or specialism, this simple bedside handbook provides handy, pragmatic guidance to the day-to-day fundamentals of working in an intensive care unit, often a daunting prospect for the junior doctor, nurse and allied health professional encountering this challenging environment for the first time.

Thoroughly updated, the second edition addresses recent and future developments in a variety of areas and is now organised into easy-to-read sections with clearly outlined learning goals. New topics added include sepsis, ARDS, refractory hypoxia, the role of allied health professionals, post ICU syndrome and follow up, and consent and capacity including new DOLS guidance. The book is authored by world-renowned contributors and edited by established consultants in the field of intensive care medicine.

PART

1

BASICS

1 Your first day and what to expect

James Turner and Joyce Yeung

2 The daily review of a patient

Shondipon K. Laha

3 Communication

Mark Pugh and Robert Fallon

4 Capacity and consent

Angela Day and Michael Elliot

5 FOAMed and social media as an aid to education in intensive care

Jonathan Downham

6 Research in intensive care

Catriona Frankling and Gavin Perkins

7 Stress and burnout in intensive care medicine: Looking after yourself

Olusegun Olusanya and Adrian Wong

1

Your first day and what to expect

JAMES TURNER AND JOYCE YEUNG

The ‘usual’ day

Who to ask for help

ICU terminology

The idea of your first day working in intensive care can be a daunting prospect. In the remainder of the hospital, the intensive care unit (ICU) is often perceived as a vastly complex world of ‘life support’, ventilators and inotropes. In reality, with the benefit of time, you will realise that the ICU continues the basic tenets of treatment carried out in the rest of the hospital, except with closer monitoring and some additional interventions, which require a high staff-to-patient ratio. Often, basic medical treatment is continued but with the addition of organ support, to maintain physiology in as normal a state as possible, allowing time for the actual treatment of the underlying condition to work. Using sepsis as an example, the treatment is antimicrobial medication. However, the profound vasodilation and resulting hypotension could result in death before the antibiotics can work. Vasoactive agents are employed to maintain end-organ perfusion while the antibiotics and the patient’s own immune system work to combat the cause of the sepsis.

Patients are admitted to the ICU for a number of reasons. Common indications for ICU admission include hypotension unresponsive to fluid resuscitation (e.g. sepsis), myocardial infarction, cardiac arrest, requirement for advanced respiratory support (e.g. severe asthma, COPD exacerbation), requirement for sedation, head injury, status epilepticus, cardiac arrest, severe liver disease, advanced post-operative monitoring due to comorbidities or severity of surgery (e.g. laparotomy, aortic aneurysm repair) and requirement for renal support. This admission may be planned or emergent, with emergencies making up over 75% of admissions. Survival to discharge from critical care varies dramatically depending on the reason for admission and any physiological impairment but is approximately 85%, including elective admissions. Patients admitted from the emergency department have a 71% survival to critical care discharge.

THE ‘USUAL’ DAY

The first day on the ICU will almost certainly start differently compared to how you have worked in other specialties. The handover from the night team to the day team is a vital part of patient care, and is taken seriously. The style of this varies between units, from a detailed ‘board round’ to walking around the unit handing over each patient at the bedside. Important information regarding the patients’ progress throughout the preceding shift as well as areas of concern and plans for the day is communicated. The time taken for the handover chiefly depends on the size of the unit and the dependency of the patients, but in a large ICU it is not unusual for the handover to take over half an hour.

Once the handover is completed, patient reviews will begin (often after a morning coffee). This consists of a full assessment of each patient, reviewing all aspects of their treatment, including a review of the medical history, investigation results, medication charts, fluid and nutritional requirements and physiotherapy requirements. Physical examination using the ABCDE approach, which is familiar to all medical graduates, is a very useful scheme to make sure nothing is omitted until one becomes familiar enough to develop one’s own system. The daily review is covered in detail in Chapter 2.

During the daily review, you will be confronted with the vast array of equipment in each bed space. There will be a monitor screen with more sections than you might expect, and each patient may well be connected to a host of syringe drivers and infusion pumps, in addition to a ventilator and other organ support. To the ICU beginner this can be an intimidating sight; however, with time this becomes part of the scenery! The details of this complex equipment are discussed in later chapters, but on your first day there are a few things worth looking at early on. The ICU chart is a repository of useful information. The format can differ but the essential elements remain the same. Routine observations you might expect to see on a ward chart are documented, in general at least hourly, but in addition to this you may well find ventilator parameters, blood gas results, detailed fluid balance monitoring, neurological observations and much more. Much of the information you re...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Foreword
• Acknowledgements
• Editors
• Contributors
• Introduction
• Part 1 Basics
• Part 2 Staffing on the Intensive Care Unit: The Multidisciplinary Team
• Part 3 Initial Assessment: The First Hour
• Part 4 Drugs
• Part 5 Equipment and Investigations
• Part 6 Airway and Respiratory Emergencies
• Part 7 Other Emergencies
• Part 8 Management
• Index