Anesthesiaworld

When you go for your first month ICU postings……?

It is a combination of excitation, impending grueling work, increased responsibility, fear of questions, anxiety about learning new skills, so on and so forth.

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General structure and functioning of Intensive Care Units

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1. An ICU can be a multidisciplinary ICU (MICU), Surgical ICU, Cardiac ICU, Neurosurgical/ neuro ICU. Anesthesia residents are most likely to be working in the first two of these, MICU and SICU.
2. ICU is an area where the dynamism is at its peak as it is here that the critically ill patients are care cared for.
3. ICU works within the general principles of ICU care as well as institutional and departmental guidelines.
4. ICU may be closed ICU where a trained/qualified intensivist is solely responsible for both clinical and administrative management of ICU with only minimal reference from different specialties. Alternately, ICU could be managed by a team of doctors from different specialties.
5. There are admission criteria and scoring systems for admitting a patient to ICU.
6. ICU is a high stress environment for the ICU staff.
7. Antibiotics management in ICU is not always same as in a non-critical set up.
8. Many patients are in/ are at risk of multiorgan failure.
9. Sudden cardiac arrest is not uncommon. So are life threatening complications.
10. Modern ICUs may also have to care for brain dead organ donor patients.
11. The staff working in ICU are exposed to serious, drug resistant infections.

Initially for a new entrant to work in ICU, often it looks quite hostile, bear with it! One day in future, you may be running a similar ICU.

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Responsibilities of residents in ICU

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1. To know the patients present in each bed, on the first day.
2. Introduction to all the ICU staff. Try to remember the names, be courteous, sincere and clear in communication. You can’t do anything in ICU without full cooperation of nursing staff.
3. To know the status of each patient in the beginning of the postings including diagnosis and treatment being given.
4. Establish ventilation/invasive monitoring as required.
5. Monitoring the patients and managing ventilation.
6. Performing/assisting emergency procedures when required.
7. Participating in discussion.
8. Transfer of patients inter and intrahospital.
9. Supervising and guiding work of paramedical staff.
10. Following infection control guidelines. Handwash, performed appropriately, is one of the most important safeguards against transfer or transmission of infection in ICU.
11. Participating in academic activities.

ICU duties often last for up to 14h because of need to complete responsibilities assigned and to participate in rounds. Always carry a notebook during ICU rounds and note down a) works to be done for each patient b) tasks given to you and 3) learning points as the discussion goes on.

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Procedures performed in ICU

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1. Endotracheal Intubation
2. Tracheostomy
3. Cricothyroidotomy
4. Percutaneous tracheostomy
5. Mechanical ventilation (Noninvasive and invasive)
6. Weaning and extubation
7. Cardiopulmonary resuscitation
8. Central venous access
9. Arterial cannulation
10. Ultrasound guided procedures
11. Intercostal drainage (ICD), mostly by surgeons, but anesthesiology residents would do well to observe and learn
12. Cardioversion and defibrillation
13. Blood transfusion
14. Needle thoracentesis for tension pneumothorax
15. Bronchoscopy, rigid and fiberoptic
16. Pacing, transvenous
17. Intracranial pressure monitoring, usually by neurosurgeons
18. Urinary catheter insertion
19. Rarely other minor surgical procedures, if patient is in a poor condition not fit to be transferred to the operation theatre.

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What you should read before going to ICU?

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1. Admission criteria
2. ICU severity scoring systems to assess the severity, monitor progress and predict outcome
3. Airway management in ICU
4. Indications for mechanical ventilation, noninvasive and invasive
5. Basics of monitoring
6. Arterial cannulation and Central line insertions: Ultrasound guided technique are now standard
7. Arterial blood gas analysis (ABG) : collection, transport and interpretation
8. Cardiopulmonary resuscitation
9. Interpretation of X Ray Chest and various investigations
10. Life threatening emergencies
11. ARDS and Sepsis
12. Vasoactive drugs: Dose, infusion rates, complications etc. Commonly include noradrenaline, adrenaline, phenylephrine, dopamine, dobutamine, inotropes
13. Sedatives and muscle relaxants: use in ICU

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Details of what you do

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Airway

Endotracheal intubation: Gold standard of airway protection and management in ICU

Indications

1. a) Protection of airway (any unconscious / deteriorating conscious level patient)
2. b) Mechanical ventilation
3. c) Performing procedures like bronchoscopy for diagnostic indications or for biopsy, lavage etc
4. d) Transfer of patients
5. e) Tracheal toileting

Techniques

1. Direct laryngoscopy: Most common technique, with or without boogie
2. Fiberoptic guided techniques
3. Intubation through supraglottic airway device
4. Blind techniques (hardly any role)

For successful and atraumatic intubation, preprocedural assessment for factors suggesting technical difficulty (anatomically difficult airway) and/or factors predisposing to rapid desaturation (physiologically difficult airway) should be done. Both can coexist in the same patient. Added to this, the difficulty of access to head end, limited resources, lack of trained manpower, hemodynamic instability and urgent nature of indication increase the risk of complications most important of which are hypoxia and aspiration.

Drugs usage and dose also differ from the way they are used in OT.

1. a) patient may already be on infusion of sedatives, additional small dose may be enough
2. b) standard induction dose of propofol can lead to profound hypotension. Titrated doses of propofol, thiopentone, ketamine etc can be used when required. Etomidate use in ICU is generally avoided because of its suppressive effect on 11Beta hydroxylase enzyme in adrenal gland.
3. c) Muscle relaxants may or may not be required and has to be decided carefully
4. d) With some indications like cardiac arrest, intubation can be performed without any drug

Confirming endotracheal tube position

1. a) Use of ETCO2; Monitor for continuous wave form for at least 6 waves
2. b) Ultrasound to observe real time passing of the tracheal tube and for bilateral lung sliding sign after connecting to ventilator
3. c) Bilateral equal air entry
4. d) direct confirmation by visualizing carina using a fiberoptic scope passed through the endotracheal tube

Breathing (Ventilation)

1. Connecting to ventilator and initial settings
2. Monitoring the adequacy of ventilation and making appropriates changes to ventilation
3. Ordering basic and initial investigations to aid appropriate ventilation
4. Reviewing the ventilatory settings to optimize the patient ventilator synchrony and to get the best support
5. Anticipate, prevent, recognize and manage problems in a systematic way

Initial settings for a given patient depends on a) indication for ventilation b) Status of lungs/oxygenation c) Ventilator available d) specific objectives to be met

General points

1. Mode: volume controlled or pressure-controlled modes. Most commonly traditionally used mode is Synchronized Intermittent Mandatory Ventilation (SIMV). Now the tendency is to select pressure-controlled mode (PCV).
2. The parameters on the ventilators are 1) set parameters, set by the user 2) monitored parameters and 3) Alarm limits (set by the user and default, both). Set parameters controlling ventilation depend on mode chosen and the goals of ventilation.
3. Objectives of ventilation are 1) optimal oxygenation, restoration, or prevention of hypoxia 2) elimination of carbon dioxide 3) indirect objectives like reduction in intracranial pressure. While achieving the objectives, settings have to be chosen in such a way lung injury is not caused or worsened.

Circulation

1. Intravenous access : peripheral and central, their roles, techniques of insertion including guidelines
2. Intraarterial blood pressure monitoring : Sites, technique and management
3. Fluids and blood : Types, assessment, monitoring
4. Use of drugs for maintaining circulation

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