Chapter 20. Critical Care

Patients admitted to the ICU often have multisystem disease, have traumatic injuries, or are under intensive treatment regimens to avoid or manage end-organ dysfunction. The interactions between dysfunctional organ systems are complicated and can be overwhelming to students and new house officers. This chapter describes an organ-system approach to evaluating and treating critically ill patients as well as commonly encountered critical care complications. The field of critical care medicine is rapidly advancing, and evidence-based protocols and pathways are becoming an important part of clinical practice. Become familiar with unit protocols in the following major areas:

• 1. Sedation and analgesia

  2. Delirium and substance withdrawal

  3. Nutrition

  4. Intensive insulin therapy

  5. Transfusion of blood products

  6. DVT and stress ulcer prophylaxis

  7. Weaning from mechanical ventilation

  8. Antibiotics

  9. Management of sepsis including:

  • a. Goal-directed therapy

    b. Activated protein C (drotrecogin alfa)

    c. Adrenal insufficiency and use of steroids

    d. Vasopressors

    e. ARDS

The ICU progress note is a concise summary of the events of the past 24 h, medications, physical exam, laboratory data, and the assessment and treatment plan. Although the information can be found elsewhere in the chart, the physician’s interpretation of the data communicates the medical decision-making process. The daily progress note includes:

• 1. Problem list and injury summary

  • a. Active problems and major inactive problems

    b. Allergies

    c. Past medical or surgical history relevant to the present illness

    d. Notation of hospital day, post trauma day, postoperative day, etc

  2. Events and procedures over the past 24 h

  3. Current medications

  4. System-specific physical exam and pertinent flow sheet data

  • a. CNS: CNS functioning or other neurologic assessment and sedation level (eg, Modified Ramsay Sedation scale, Richmond Agitation–Sedation Scale [RASS], Confusion Assessment Method [CAM-ICU])

    b. CV: Cardiovascular function, including indicators of systemic perfusion, blood pressure, heart rate, and pulmonary artery (PA) catheter data

    c. Pulm: Pulmonary function, including ventilator settings and ABG values

    d. GI/Nut: GI function and nutritional status

    e. F/E/R: Fluids, electrolytes, and renal function

    f. Heme/ID: Hematologic function, including CBC, coagulation values; infectious disease status (recent culture data, antibiotic regimen, treatment duration)

    g. Prophylaxis: DVT, ethanol withdrawal, stress gastritis, etc

  5. Other relevant laboratory and radiographic data

  6. Assessment and plan

• 1. Continuous ECG: Computerized arrhythmia detection systems facilitate rapid detection of rhythm abnormalities and increase the likelihood of successful resuscitation.
• 2. Blood Pressure: Intermittent (sphygmomanometer) or continuous (intravascular) assessment of BP (systolic, diastolic, mean arterial, and central venous pressures). Assessment of response to treatment and titration of vasoactive drugs. Continuous intravascular methods are warranted in patients with marked hemodynamic instability.
• 3. Pulse Oximetry: Continuous, quantitative arterial O2 saturation (Sao2); ensures adequate oxygenation of systemic arterial blood for tissue delivery.
• 4. Temperature: Critically ill patients are at high risk of thermoregulatory disorders due to their pathophysiologic condition (eg, fluid resuscitation, burns, sepsis); continuous measurements in the esophagus (esophageal probe) and central venous blood compartment (PA ...