intensive care unit (ICU)

Indications

indications for admission to the ICU

• unstable airway
• unstable blood pressure
• unstable mental status
• life-threatening cardiac arrhythmia
• respiratory failure
• severe metabolic disease
• need for assessment of vital signs more frequently than every 2 hours

Complications

• delirium is common
  • advanced age & cognitive impairment are risk factors
  • identify & treat underlying cause
  • haloperidol prophylaxis of no value
• 1/3 of survivors have depression or impairment in activities of daily living
  • depression is 5X more common than PTSD
  • all ages affected
• premorbid disability, poor functional status, & deteriorating functional trajectory in the elderly are associated with high 1 year mortality (see critical disease)
• socioeconomic disadvantage associated with more disability & dementia after ICU stay

Management

• conservative oxygen therapy is associated with lower mortality in the ICU (12% vs 20%)
  • use lowest FiOA to maintain SaO2 of 94-98%
• non-invasive ventilation for respiratory failure when possible
  • immunocompromised patients
  • heart failure
  • COPD exacerbation
  • postoperative hypoxemia
• treat non-neuropathic pain with opiates
• aggressive & frequent interventions may result in adverse consequences from stress of procedures
• more aggressive triage & transfers to the floor during times of ICU capacity strain don't result in higher mortality
• early physical therapy & occupational therapy improves outcomes among mechanically ventilated ICU patients
  • early mobilization of ICU patients decreases ICU stay & hospital stay, improves function, & reduces mortality
  • early mobilization of ICU patients on low dose vasopressor is safe
• prophylactic antibiotics for respiratory tract infection
• dietary requirements
  • initiate enteral nutrition within 24-48 hours of ICU admission if patient is hemodynamically stable
  • advance to goal by 49-72 hours
  • 25-30 non-protein kcal/kg/day to meet energy needs of critically ill patients
  • dietary protein 1.0-1.5 g/kg/day
  • low-calorie, low-protein enteral nutrition may reduce ICU stay in ventilated patients
  • weekly reassessment of pediatric patients
• do not use parenteral nutrition in adequately nourished ICU patients within the 1st 7 days of an ICU admission
  • consider supplemental parenteral nutrition after 7-10 days of enteral nutrition meeting < 60% of protein & energy requirements
• peripheral intravenous access with a short, wide-bore catheter for rapid volume resuscitation
• RBC transfusion threshold for hemodynamically stable, non-bleeding patients in the ICU is a blood hemoglobin of < 7 g/dL
• remove intravenous access as soon as possible
• do not deeply sedate mechanically ventilated ICU patients without specific indication & without daily attempt to lighten sedation with a trial of spontaneous respirations
• sedation & analgesia should be monitored with objective standardized scales
• do not support futile care without palliative care consult or offering comfort care only
• intensivist staffing in intensive care units is associated with lower mortality (daytime or nighttime but not both)
• nighttime in-hospital intensivist staffing may or may not improve patient outcomes
• music therapy lowers anxiety in the ICU
• daily checklists do not reduce mortality
• early mobilization decreased length of ICU stay & hospital stay & improves functional status & quality of life
• family-support intervention
  • no benefit for surrogates' burden of psychological symptoms
  • ratings of communication & care better
  • length of ICU stay shorter
  • structured family conference combining communication with a brochure on bereavement reduces anxiety, depression, & post-traumatic stress disorder among family members of ICU patients
• providing surrogates with summaries written in easy-to-comprehend language can help with understanding complex medical issues
  • may be more helpful than providing surrogates access to medical records
  • does not affect surrogate's anxiety or depression
• patients may be directly discharge home from ICU
  • no increase in mortality or health care utilization
  • diabetes complications & drug overdoses most common diagnoses of those patients directly discharged home from the ICU, pneumonia less common

Notes

• hospitalists provide critical care to many ICU patients
  • 1/3 may practice beyond their ICU skill level
  • U.S. graduate fellowship programs may not have enough training positions to fill the need for board-certified intensivists

More general terms

• hospital unit

More specific terms

• medical intensive care unit (MICU)
• neonatal intensive care unit (NICU)
• surgical intensive care unit (SICU)

Additional terms

• critical care medicine
• critical illness syndrome
• post intensive care unit (ICU) syndrome
• prophylaxis for ICU respiratory tract infection

Patient information

intensive care unit patient information