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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 [3] Complications: - delirium is common - advanced age & cognitive impairment are risk factors - identify & treat underlying cause - haloperidol prophylaxis of no value [8] - 1/3 of survivors have depression or impairment in activities of daily living [10] - 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 [19] Management: - conservative oxygen therapy is associated with lower mortality in the ICU (12% vs 20%) [14] - use lowest FiOA to maintain SaO2 of 94-98% [14] - non-invasive ventilation for respiratory failure when possible - immunocompromised patients [3] - heart failure - COPD exacerbation - postoperative hypoxemia - treat non-neuropathic pain with opiates [3] - aggressive & frequent interventions may result in adverse consequences from stress of procedures [4] - more aggressive triage & transfers to the floor during times of ICU capacity strain don't result in higher mortality [9] - early physical therapy & occupational therapy improves outcomes among mechanically ventilated ICU patients [2,3,12] - early mobilization of ICU patients decreases ICU stay & hospital stay, improves function, & reduces mortality [3] - early mobilization of ICU patients on low dose vasopressor is safe [3] - prophylactic antibiotics for respiratory tract infection [11] - dietary requirements a) initiate enteral nutrition within 24-48 hours of ICU admission if patient is hemodynamically stable [3,15] b) advance to goal by 49-72 hours [3] c) 25-30 non-protein kcal/kg/day to meet energy needs of critically ill patients d) dietary protein 1.0-1.5 g/kg/day [3,15] e) low-calorie, low-protein enteral nutrition may reduce ICU stay in ventilated patients [22] f) weekly reassessment of pediatric patients [15] - do not use parenteral nutrition in adequately nourished ICU patients within the 1st 7 days of an ICU admission [3] - consider supplemental parenteral nutrition after 7-10 days of enteral nutrition meeting < 60% of protein & energy requirements [3] - peripheral intravenous access with a short, wide-bore catheter for rapid volume resuscitation [3] - RBC transfusion threshold for hemodynamically stable, non-bleeding patients in the ICU is a blood hemoglobin of < 7 g/dL [3] - remove intravenous access as soon as possible [3] - do not deeply sedate mechanically ventilated ICU patients without specific indication & without daily attempt to lighten sedation with a trial of spontaneous respirations [3] - sedation & analgesia should be monitored with objective standardized scales [3] - do not support futile care without palliative care consult or offering comfort care only [3] - intensivist staffing in intensive care units is associated with lower mortality [3] (daytime or nighttime but not both) [5] - nighttime in-hospital intensivist staffing may [3] or may not [5] improve patient outcomes - music therapy lowers anxiety in the ICU [6] - daily checklists do not reduce mortality [13] - early mobilization decreased length of ICU stay & hospital stay & improves functional status & quality of life [3] - family-support intervention [17] - no benefit for surrogates' burden of psychological symptoms - ratings of communication & care better - length of ICU stay shorter [17] - 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 [20] - may be more helpful than providing surrogates access to medical records - does not affect surrogate's anxiety or depression [20] - patients may be directly discharge home from ICU - no increase in mortality or health care utilization [18,21] - diabetes complications & drug overdoses most common diagnoses of those patients directly discharged home from the ICU, pneumonia less common [21] Notes: - hospitalists provide critical care to many ICU patients - 1/3 may practice beyond their ICU skill level [16] - U.S. graduate fellowship programs may not have enough training positions to fill the need for board-certified intensivists [16]

Related

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

Specific

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

General

hospital unit

References

  1. Diagnostic History & Physical Examination in Medicine, Chan & Winkle, Current Clinical Strategies, Laguna Hills, CA 1996
  2. Schweickert WD et al Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial Lancet, Early Online Publication, 14 May 2009 doi:10.1016/S0140-6736(09)60658-9 PMID: 19446324 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)60658-9/fulltext
  3. Medical Knowledge Self Assessment Program (MKSAP) 15, 17, 18, 19. American College of Physicians, Philadelphia 2009, 2015, 2018, 2022.
  4. Journal Watch Psychiatry, November 7, 2011 Massachusetts Medical Society Commnent to article by Smith et al - Smith GC et al. Neonatal intensive care unit stress is associated with brain development in preterm infants. Ann Neurol 2011 Oct; 70:541. PMID: 21976396
  5. Journal Watch, July 26, 2012 Massachusetts Medical Society - Wallace DJ et al. Nighttime intensivist staffing and mortality among critically ill patients. N Engl J Med 2012 May 31; 366:2093 PMID: 22612639
  6. Chlan LL et al. Effects of patient-directed music intervention on anxiety and sedative exposure in critically ill patients receiving mechanical ventilatory support: A randomized clinical trial. JAMA 2013 Jun 12; 309:2335. PMID: 23689789
  7. Kerlin MP et al. A randomized trial of nighttime physician staffing in an intensive care unit. N Engl J Med 2013 Jun 6; 368:2201 PMID: 23688301
  8. Page VJ et al Effect of intravenous haloperidol on the duration of delirium and coma in critically ill patients (Hope-ICU): a randomised, double-blind, placebo-controlled trial. Lancet Respir Med. August 21, 2013 PMID: 24461612 http://www.thelancet.com/journals/lanres/article/PIIS2213-2600(13)70166-8/abstract - Skrobik Y, Can critical-care delirium be treated pharmacologically? Lancet Respir Med. August 21, 2013 PMID: 24461599 http://www.thelancet.com/journals/lanres/article/PIIS2213-2600%2813%2970178-4/fulltext - Girard TD et al. Feasibility, efficacy, and safety of antipsychotics for intensive care unit delirium: The MIND randomized, placebo- controlled trial. Crit Care Med 2010 Feb; 38:428. PMID: 20095068
  9. Wagner J et al. Outcomes among patients discharged from busy intensive care units. Ann Intern Med 2013 Oct 1 PMID: 24081285 http://annals.org/article.aspx?articleid=1742592
  10. Jackson JC et al Depression, post-traumatic stress disorder, and functional disability in survivors of critical illness in the BRAIN-ICU study: a longitudinal cohort study. Lancet Respir Med. April 7, 2014 PMID: 24815803 http://www.thelancet.com/journals/lanres/article/PIIS2213-2600%2814%2970051-7/abstract - Prescott HC and Iwashyna TJ Somatic symptoms in survivors of critical illness. PMID: 24815798 Lancet Respir Med April 7, 2014 PMID: 24815798 http://www.thelancet.com/journals/lanres/article/PIIS2213-2600%2814%2970071-2/fulltext
  11. The NNT: Prophylactic Antibiotics for Reducing ICU Respiratory Tract Infections and Mortality in Adults. http://www.thennt.com/nnt/antibiotics-prophylactic-for-icu-respiratory-infections/ - Liberati A, D'Amico R, Pifferi S, Torri V, Brazzi L, Parmelli E Antibiotic prophylaxis to reduce respiratory tract infections and mortality in adults receiving intensive care. Cochrane Database Syst Rev. 2009 Oct 7;(4):CD000022 PMID: 19821262
  12. Engel HJ, Needham DM, Morris PE, Gropper MA. ICU early mobilization: from recommendation to implementation at three medical centers. Crit Care Med. 2013 Sep;41(9 Suppl 1):S69-80 PMID: 23989097
  13. Writing Group for the CHECKLIST-ICU Investigators and the Brazilian Research in Intensive Care Network (BRICNet). Cavalcanti AB, Bozza FA, Machado FR et al Effect of a quality improvement intervention with daily round checklists, goal setting, and clinician prompting on mortality of critically ill patients: A randomized clinical trial. JAMA 2016 Apr 12; 315:1480. PMID: 27115264
  14. Girardis M, Busani S, Damiani E et al Effect of Conservative vs Conventional Oxygen Therapy on Mortality Among Patients in an Intensive Care Unit. The Oxygen-ICU Randomized Clinical Trial. JAMA 2016 Oct 18; 316:1583 PMID: 27706466 http://jamanetwork.com/journals/jama/article-abstract/2565306 - Ferguson ND Oxygen in the ICU. Too Much of a Good Thing? JAMA 2016 Oct 18; 316:1553 PMID: 27706469 http://jamanetwork.com/journals/jama/fullarticle/2565302
  15. Anello J, Feinberg B, Heinegg J et al Nutritional Support in Critically Ill Pediatric Patients. Guidelines on nutritional support for pediatric critically ill patients by the Society of Critical Care Medicine and the American Society for Parenteral and Enteral Nutrition. Medscape: New Guidelines and Recommendations, August 2017. http://reference.medscape.com/viewarticle/884517
  16. Sweigart JR, Aymond D, Burger A et al. Characterizing hospitalist practice and perceptions of critical care delivery. J Hosp Med 2018 Jan; 13:6. PMID: 29240847 https://www.journalofhospitalmedicine.com/jhospmed/article/152886/hospital-medicine/characterizing-hospitalist-practice-and-perceptions - Flanders SA, Cooke CR. Hospitalists in the ICU: Necessary but not sufficient. J Hosp Med 2018 Jan; 13:65. PMID: 29240848 https://www.journalofhospitalmedicine.com/jhospmed/article/152887/hospital-medicine/hospitalists-icu-necessary-not-sufficient
  17. White DB, Angus DC, Shields AM et al for the PARTNER Investigators A Randomized Trial of a Family-Support Intervention in Intensive Care Units. N Engl J Med. May 23, 2018 PMID: 29791247 https://www.nejm.org/doi/full/10.1056/NEJMoa1802637
  18. Stelfox HT, Soo A, Niven DJ et al Assessment of the Safety of Discharging Select Patients Directly Home From the Intensive Care Unit. A Multicenter Population-Based Cohort Study. JAMA Intern Med. Published online August 20, 2018 PMID: 30128550 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2697392 - Safavi K, Wiener-Kronish J, Hanidziar D The Complexity and Challenges of Intensive Care Unit Admissions and Discharges. Similarities With All Hospitalized Patients. JAMA Intern Med. Published online August 20, 2018 PMID: 30128564 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2697390
  19. Jain S et al. Association between socioeconomic disadvantage and decline in function, cognition, and mental health after critical illness among older adults: A cohort study. Ann Intern Med 2022 Mar 8; [e-pub]. https://www.acpjournals.org/doi/10.7326/M21-3086
  20. Greenberg JA et al. Daily written care summaries for families of critically ill patients: A randomized controlled trial. Crit Care Med 2022 Sep; 50:1296. PMID: 35607975 https://journals.lww.com/ccmjournal/Abstract/2022/09000/Daily_Written_Care_Summaries_for_Families_of.2.aspx
  21. Lau VI et al. Safety outcomes of direct discharge home from ICUs: An updated systematic review and meta-analysis (Direct from ICU Sent Home study). Crit Care Med 2023 Jan; 51:127. PMID: 36519986 PMCID: PMC9750104 Free PMC article https://journals.lww.com/ccmjournal/Fulltext/2023/01000/Safety_Outcomes_of_Direct_Discharge_Home_From.14.aspx
  22. Reignier J, Plantefeve G, Mira JP et al. Low versus standard calorie and protein feeding in ventilated adults with shock: A randomised, controlled, multicentre, open-label, parallel-group trial (NUTRIREA-3). Lancet Respir Med 2023 Jul; 11:602. PMID: 36958363 Clinical Trial. https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(23)00092-9/fulltext