CONTENTS

CONCEPTS OF ICU
CRITICAL CARE UNITS
GUIDELINES FOR DESIGINING A CRITICAL CARE UNIT
OPEN
CLOSED
DESIGN
LIGHTING
VENTILATION
AIRFLOW
TEMPERATURE
HUMIDITY
CARDIAC MONITOR
CENTRAL LINE
TRACHEOSTOMY

ICU- DEFINITION
Service for patients with potentially recoverable diseases who can be benefit from
more detailed observation and treatment than is generally available in standard wards and
departments.
Or
The critical care or intensive care unit is the term used to describe “the care of patient
who are extremely ill and whose clinical condition is unstable or potentially unstable.”

CONCEPTS OF ICU
1. More care – Continuous and Intensive
2. Specialty care
3. Source of Areas (Medical, surgical etc)
4. Open and closed units
5. Provides advanced life support through the application of technology
6. Initial assessment of airway, breathing and circulation and intervention.
FUNCTION OF ICU
1. Provide optimum life support
2. Provide adequate monitoring of vital functions

TYPES OF ICU
❖ General
1. Medical intensive care unit (MICU)
2. Surgical intensive care unit
3. Medical surgical intensive care unit (MSICU)
❖ Specialized
1. Neonatal intensive care unit (NICU)
2. Special care nursery (SCN)
3. Pediatric intensive care unit (PCIU)
4. Coronary care unit (CCU)
5. Cardiac surgery intensive care unit (CSICU)
6. Neuro surgery intensive care unit (MSICU)
7. Burn intensive care unit (BICU)
8. Trauma intensive care unit

ORGNIZING AN ICU

By clinical syndrome By Traditional

ICU

By organ system By clientele

By traditional specialties: Surgical, Medical, Pediatric

By organ system: Cardiac, Neuro, Renal, Respiratory
By clinical syndrome: Burn, Trauma, stroke
By clientele: Neonatal, Pediatric, Gynae
ITU- Intensive treatment unit
Highest level of patient dependency, most aggressive treatment and monitoring
protocols Eg- Cardiac surgery units

SCBU – Special care baby unit

Neonatal problems often requiring IPPV and invasive monitoring techniques

HDU – High dependency unit

Recovering area of an operating theatre with low level of monitoring and high level of
nursing care

PREPARATION OF THE UNIT:

The unit should be kept ready all the time which should include the following
1. Special bed having the following facilities
• Head board should be detachable to facilitate intubation (in case of cardiopulmonary
arrest)
• Bed should be firm and non-yielding to facilitate cardiac massage
• Should have a tilting mechanism (to keep position of patient)
• Should have side rails to prevent falling (Psychiatric and anxious patient)
• There should be a bedside locker an over bed table and a foot stool kept adjacent to
the bed
2.Cardiac monitor system with alarm that maybe connected to the central console
3.Oxygen and suction apparatus (Preferably pipe line model)
4.Resuscitation unit containing the following
• Syringes, needles, IV cath, intravenous administration sets, blood sets, scalp vein sets
and intravenous fluid
• Spirit, swabs, adhesive plaster (micropore/transpore), torniquets and arm board
• Airways, endotracheal tubes and laryngoscopes of different sizes
• Ambu bag and suction catheters
• Oxygen cylinders special trays such as tracheostomy tray and catheterization tray
• Drugs such as (antiarrhythmics, antianginal, antihypertensive, diuretic, anticoagulants,
antibiotics, anticonvulsants etc)
• Infusion pump
5.Following equipment’s should be easily available
• Defibrillator in working mode with electrodes and jell
• Cardiac pacemaker with pacing catheters in the sterile tray
• Mechanical ventilators (to ventilate the lungs in case of respiratory arrest)
• Facility for invasive and noninvasive procedure like CVP line, intra-arterial pressure
monitor)
• Portable X-ray machine
• ECG machine
• Oxygen therapy
•
GUIDELINES FOR DESIGNING A CRITICAL CARE UNIT
❖ Open Units:
Definition – Any attending physician with hospital admitting privileges can be the
physician of record and direct ICU care
Disadvantages:
Lack of a cohesive plan
Inconsistent night coverage
Duplication of services

❖ Closed Units:
Definition – An intensivist is the physician of record for ICU patients. (other
physicians are consultants). All orders and procedure carried out by ICU stage
Advantages:
Improved efficiency
Standardized protocol for care
Disadvantages:
Potential to lock out private physician
Increase physician conflict

DESIGN OF ICU
• Should be at geographically distinct area within the hospital, with controlled access.
• There should be a single entry and exit. However, it is required to have emergency
exit points in case of emergency and disaster
• There should not be any through traffic of goods or hospital staff.
• Location - Safe, easy, fast transport of a critically sick patient should be a priority in
planning its location. Therefore, ICU should be located in close to emergency OT,
trauma ward.
• Corridors, lifts and ramps should be spacious enough to provide easy movement of
bed/trolley of a critically sick patient
 • Close, easy proximity is also desirable to diagnostic facilities, blood bank, pharmacy
etc.

❖ Bed Strength:
• It is recommended that total bed strength in ICU should be between 8-12 and not
less than 6 or not more than 24 in any case.
• 3-5 beds per 100 hospital beds for a level III ICU or 2 to 20% of the total no of
hospital beds
• 1 isolated bed for every ICU beds

❖ Bed and its space:

• 150-200sq.feett per open bed with 8 feet in between beds
• 225-250sq.feet per bed if in a single room
• Beds should be adjustable, no head board, with side rails and wheels
• Keep bed 2 feet away from head wall.

❖ Bed head fixture and call bell system

• Wall panels and call button near the bed
• Sufficient electric socket (10 -15) for plugging
• Sockets should be 120 – 180cm above ground
• Wall suctioned tube and piped oxygen supply
• High intensity spot light
• Small wash basin
• Equipment with CV stabilizer and UPS

❖ Accessories:
1. 3 O2 Outlets, 3 suction outlets (gastric, tracheal and underwater seal), 2
compressed air outlets and 16 power outlets per bed
2. Storage by each bedside
3. Hand rinse solution by each bedside
4. Equipment shelf at the head end
5. Hooks and devices to hang infusions/ blood bags, extended from the ceiling with a
sliding rail to position
6. Infusion pumps to be mounted on stand or poles
7. Level II ICUs may require multichannel invasive monitors
8. Ventilators, infusion pumps, portable X ray unit, fluid and bed warmers, portable
light, defibrillators, anesthesia machines and difficult airway management
equipment’s are necessary,
❖ Environmental requirements:
1. Air condition
• ICU must be air conditioned.
• Temperature must be maintained at 25 -27 centigrade and 40 -50% humidity.

2. Ventilation
• 6 to 8 air change/hour.
• Filter less than 10 micron. It is recommended that all air should be filtered to
99% efficiency down to 5 microns.
• Positive pressure flow from patient area to outside

3. Lightning
Light in room:
• Natural light – access to outside natural light is recommended
• It may be helpful in maintaining the circadian rhythm
• Natural lighting in the unit can decrease power consumption and the electrical
bill which is so relevant to Indian circumstances
Lighting for Procedure:
• High illumination and spot lighting is needed for procedures, like putting
central line etc.
• They can descend from the ceiling, extend from the wall/panel, or be carried
into the room
• Recommended spot lighting should be shadow free 150 foot candle strength
Light required for general patient care:
• Overhead lighting should be at least 20 foot candles
• Patients may need rest and quiet surrounding during the day
• Lights that come on automatically when cupboard doors or drawers are
opened are useful
• Light switches should be strategically located to allow some patient control
and adequate staff convenience.

4. Temperature - 16 – 250c

5. Noise Control
Under 45dBA in day, <40dBAin evening, <20dBA in night
6. Furniture
Solid, non-porous, stain resistant, Bedside clocks, calendars and bulletin
boards help the conscious patient well oriented and in better moods

7. Floor – easy to clean and non-slippery

8. Wall – 4-5 feet finished with tiles
9. Ceiling – paint with soft color, no wire lines
CARDIAC MONITOR
❖ Definition:
It is a device that shows the electrical and pressure waveforms of the cardiovascular
system for measurement and treatment. Parameters specific to respiratory function can also
be measured

❖ Purpose:
• It continuously shows the cardiac rhythm, heart rate, BP, Respiratory rate, and
Temperature
• It is used in emergency rooms and critical care areas, for continual observation of
critically ill patients
• It is useful for observation of postoperative patients, patients with severe electrolyte
imbalances, and other unstable patients.
• Continuous cardiac monitoring allows for prompt identification and initiation of
treatment for cardiac arrhythmias and other conditions
• The cardiac monitor continuously displays the cardiac ECG tracing
• It also monitor cardiovascular pressures and cardiac output
• Oxygen saturation of the arterial blood can also be monitored continuously
• It can be interconnected in critical care areas to allow for continual observation of
several patients from a central display
• Continuous cardiovascular and pulmonary monitoring allows for prompt
identification and initiation of treatment.

❖ Equipment’s Required:
1. Cardiac Monitor
2. Monitor cable
3. Pressure transducers and BP cuff
4. Electrodes
5. Spo2 Probe

❖ Functions:
A display of heart rate and rhythm
Sound alarms above or below pre-set limits
The provision of rhythm strips to document evidence of arrhythmias

❖ Indication of cardiac monitoring

• Chest pain
• Palpitations
• Acute coronary syndrome – STEMI, NSTEMI, unstable angina
• Major surgery, trauma
• Post cardiac/respiratory arrest
• Shock, Pulmonary embolus, drug overdose, electrolyte imbalance
 • Results:
1. A normal cardiac rhythm ( P wave followed by QRS complex)
2. Abnormal results may include bradycardia, tachycardia etc which is accompanied
by the alarm
3. Abnormal ECG waves which may indicate infarction

CENTRAL LINE
Central venous catheter also known as central line, central venous line is a catheter
placed into a large vein

❖ Regular sites
Catheter can be placed in veins
• Neck (internal jugular vein)
• Chest (subclavian vein or axillary vein)
• Groin (femoral vein)
• Peripherally inserted central catheters (PICC)

❖ Central line lumen types

1. Single
2. Double
3. Triple

❖ Catheter types
1. Tunneled catheters:
Site – Neck, groin
Indication – chemotherapy, nutrition, fluids, and blood samples
2. PICC line
3. Non tunneled catheters
Site – Right internal jugular vein, femoral vein, left internal jugular vein,
subclavian vein
Indication – Hemodialysis, significant vascular disease, renal replacement
therapy

❖ Catheter Approach
1. Subclavian approach:
Position: Right side, supine position
Needle placement:
• Junction of middle and medial thirds of clavicle
• At the small tubercle in the medial deltopectoral groove
• Needle should be parallel to skin
• Aim towards the supraclavicular notch and just under the clavicle
 2. Internal jugular approach
Position: Right side, Trendelenburg position
Needle placed: central approach
• The triangle formed by the clavicle and the sternal and clavicular heads
of the sternoclavicular muscle is located
• Needles should be placed at 30 to 40 degrees to the skin, lateral to the
carotid artery
• Vein should be 1-1.5cm deep (deep probing into the neck should be
avoided)
3. Femoral approach
Position – supine
Needle placement
• Medial to femoral artery
• Needle held at 45 degree angle
• Skin insertion 2cm below inguinal ligament
• Aim toward umbilicus

❖ Uses
• To administer medicine
• Fluids that are unable to be taken by mouth
• To obtain blood test
• Measure central venous pressure (It is the blood pressure in the venaecavae, near the
RA.CVP reflects the amount of blood returning to the heart and the ability of the heart
to pump the blood back into the arterial system. Normal range for CVP is 0 to
5mmH2O)

❖ Indication
• Long-term intravenous antibiotics, parenteral nutrition in chronically ill persons
• Long-term pain medication and chemotherapy
• Insertion of pacing wires
• Frequent blood draws
• Monitoring of the central venous pressure

❖ Contraindications
• Uncorrected coagulopathy
• Thrombocytopenia
• Skin infection over the site of access
• Pneumothorax on the contralateral side
• Low platelet counts
❖ Complications:
• Bleeding
• Infection
• Puncture of adjacent structures (such as other veins or arteries)
• Air embolism
• Pneumothorax (collapse of the lung)
• Hemothorax (bleeding into the chest)
• Catheter breakage

❖ Maintenance of CV line
• Hepsol flush 8 hourly
• Central short channel is used for measuring CVP
• Rest two channels are used for medication
• The dressing should be changed at regular interval
• Catheter should not be kept for more than 3weeks.

TRACHEOSTOMY
A Tracheostomy is a artificial surgically created airway fashioned by making a hole in the
anterior wall of the trachea and the insertion of a tracheostomy tube, which may or may not
be permanent.

History:
• 1546: First successful tracheostomy Antonuius Mysa Brasavola
• 1921: Jackson defined and refined surgical airway management technique
• 1955: Percutaneous tracheostomy was described by shelden
• 1969: Toy and Weinstein described a Percutaneous Tracheostomy using the guide
wire approach of seldinger

Functions of tracheostomy:
1. Alternative pathway for breathing: circumvents obstruction in upper airway
2. Improves alveolar ventilation: decreases dead space and resistance to airflow
3. Protects airway: against aspiration
4. Permits removal of tracheobronchial secretions
5. Intermittent positive pressure respiration: if > 72 hours better than intubation
 Indications:
1. Upper airway obstruction
• Tumors (of oropharynx, larynx, upper trachea)
• Infections (epiglottis, severe tracheobronchitis)
• Bilateral vocal cord paralysis
• Trauma (laryngeal, maxillofacial fractures)
• Foreign body obstruction
• Subglottic or tracheal stenosis
2. Pulmonary ventilation
Should be performed in a patient still requiring ventilation through an
endotracheal tube for more than a one week
3. Removal of secretions
Congestive cardiac failure, infection, pulmonary edema and bulbar palsy
Those who cannot cough and clear their chest
4. Prevent aspiration
5. Elective Procedure
• For major head and neck operations that effect the patency of airway
• In patients with uncertain general conditions particularly cardiovascular or
pulmonary deficiency patient

Types of Tracheostomy
❖ Depending on the timing
1. Elective / routine
• Planned Procedure. Endotracheal tube can be inserted by giving local or general
anesthesia
• It is of two types
a) Therapeutic: To relieve respiratory obstruction, remove tracheobronchial
secretion or give assisted ventilation
b) Prophylactic: to guard against anticipated respiratory obstruction or aspiration
of blood or pharyngeal secretions such as in extensive surgery of tongue, floor
of mouth, mandibular resection or laryngofissure.

2. Emergency
• It is employed when airway obstruction is complete or almost completer
• There is urgent need to establish the airway
• Intubation or laryngotomy are either not possible or feasible in such cases

❖ Depending on the cause

1. Permanent – required for bilateral abductor paralysis or laryngeal stenosis
2. Temporary
❖ Depending on site
1. High – above the level of thyroid isthmus at 1st and 2nd tracheal rings
2. Mid – preferred one. Behind thyroid isthmus at 3rd and 4th rings
3. Low – below the level of isthmus at 5th and 6th rings

Types of Tracheostomy techniques

1. Cricothyroidotomy
2. Open tracheostomy
3. Percutaneous procedure

❖ CRICOTHYROIDOTOMY
- Emergency procedure
- When ET intubation is impossible
- Contraindicated in children less than 11 years, trauma to larynx or cricoid
cartilage
- Keep only for 3 to 5 days
Surgical steps:
1. Supine position with neck extended
2. Thyroid cartilage is gripped between thumb and middle finger
3. Move your finger down to palpate cricoid cartilage
4. Space between thyroid and cricoid cartilage is cricothyroid membrane
5. 1cm vertical incision through skin and subcutaneous tissue
6. Use curved hemostat for blunt dissection through planes
7. Use horizontal incision on cricothyroid membrane
8. Insert trousseau dilator and dilated membrane vertically
9. Insert tracheostomy tube
10. Inflate cuff with 100cc syringe
11. Attach bag valve unit and ventilate the patient
12. Secure tracheostomy tube with ties and sutures

❖ TRACHEOSTOMY SURGICAL STEPS:

1. Airway control
2. Patient Position – Supine, neck extended, pillow under the shoulder
3. Anesthesia – 1 -2 % lignocaine + epinephrine is infiltrated in the line of incision and
area of dissection
4. Identify the landmarks
5. A transverse incision 1cm below the cricoid or halfway between the cricoid and the
sternal notch
6. Refractors are placed, the skin is retracted, and the strap muscles are visualized in the
midline. The muscles are divided along the raphe, then retracted laterally.
7. The thyroid isthmus lies in the filed of the dissection. Typically the isthmus is 5 to
10mm in its vertical dimension
8. Retract it up.
 9. Identify trachea, tracheal incision in the second or third tracheal interspace
10. Tube is inserted and secured

❖ PERCUTANEOUS DILATIONAL TRACHEOSTOMY

- ICU bedside Tracheostomy
- Use of guide wire and dilators
- Under the vision of bronchoscope through endotracheal tube
- Less time, less expensive
- Not suitable for thick neck, children and emergency
- Several variants of percutaneous tracheostomy technique have developed
a) Using a wire guided sharp forceps (Griggs technique)
b) Using a single tapered dilator (Bluerhino)
c) Passing the dilator from inside the trachea to the outside (Fantoni’s technique)
d) Using a screw like device to open the trachea wall (perctwist)

Surgical steps:
1. Position – supine
2. 1st,2nd,3rd tracheal ring identified
3. Local anesthesia is given subcutaneously
4. 1.5cm vertical incision is made and blunt dissection is performed to expose the
pretracheal fascia. The trachea is palpated and the intended site is punctured with
a 14 G intravenous cannula in a postero-caudal direction
5. The entry of the IV cannula in trachea is confirmed by aspiration of air into a
saline filled syringe. A guide wire is inserted through the cannula, and the cannula
is withdrawn
6. The tracheal opening is dilated over the guide wire until a stoma of sufficient size
to accommodate the tracheostomy tube is created.
7. A tracheostomy tube is placed over the guide wire and dilator through the passage
created.

Complications:
1. Immediate
• Hemorrhage
• Air embolism
• Apnea
• Local damage (thyroid cartilage, cricoid cartilage, recurrent laryngeal
nerve)
• Cardiac arrest
• Pneumothorax/pneumomediastinum
 2. Intermediate
• Dislodgement/displacement of the tube
• Subcutaneous emphysema
• Pneumothorax/pneumomediastinum
• Infection
• Tracheal necrosis
• Tracheo-esophageal fistula
• Dysphagia

3. Late
• Tracheal stenosis
• Difficulty with decannulation
• Tracheocutaneous fistula/scar

Types of tracheostomy tubes

1. Metal tubes
• Metal tubes are constructed of silver or stainless steels
• Metal tubes are not used commonly because they are expensive, rigid
construction, uncuffed, lack connector to ventilator
2. Plastic tubes
• Can be made with cuff
• It has connector to anesthetic machine and ventilator
• Cause less mechanical damage to trachea
3. Cuffed and uncuffed – to protect airways
4. Fenestrated and unfenestrated – allow patient to ventilate past tube via upper
airway, allow speech
5. Single and double lumen
• Double lumen allows easy cleaning
• Single lumen has a greater internal diameter

TRACHEOSTOMY CARE
1. Suctioning
Regular gentle suctioning. Not aggressive and not too much deep
2. Skin care
Meticulous wound and stoma care. To prevent irritation and secondary
inflammation due to discharge
3. Inner tube care – once or more daily removed and clean
4. Humidification – artificial noise to prevent crusting of secretions
5. Tube position – to prevent decubitus of trachea. Not to cover with blanket
 6. Care of cuff
• When to inflate the cuff
a) Immediately post-operatively to prevent aspiration of blood or serous fluid
from the wound
b) To seal the trachea during mechanical ventilation
c) To prevent aspiration of leakage from trachea-esophageal fistula
d) To prevent aspiration due to laryngeal incompetence
• Deflate
a) First suction the oropharynx
b) Cuff should be deflated at least 5 mins every hour
7. Changing the tracheostomy tube
• Indication – soiled, blocked, cuff rupture, changed to smaller size or another type
• Avoid within 1st week
• First tube changed by the surgeon
• Difficult case (obese, short and thick neck) be prepared for endotracheal
intubation

Decannulation
• Should be left in place no longer than necessary
• As soon as the patients condition permits, reduce the size of the tube to avoid
physiologic dependence on a large tube
• Check for adequacy of the airway, ability to swallow and handle secretion for 24
hours and then plug the tube
• If occlusion tolerated for 24 hours, the tube is removed and the tracheocutaneous
fistula is taped shut.