Intensive care medicine
Multiorgan failure | |
Specialist | Intensive care physician Critical care physician Intensivist |
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Occupation | |
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Occupation type | Specialty |
Activity sectors | Medicine |
Description | |
Education required |
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Fields of employment | Anesthesiologist |
Intensive care medicine, also called critical care medicine, is a medical specialty that deals with seriously or critically ill patients who have, are at risk of, or are recovering from conditions that may be life-threatening.[1] It includes providing life support, invasive monitoring techniques, resuscitation, and end-of-life care.[2] Doctors in this specialty are often called intensive care physicians, critical care physicians, or intensivists.
Intensive care relies on multidisciplinary teams composed of many different health professionals. Such teams often include doctors, nurses, physical therapists, respiratory therapists, and pharmacists, among others.[3] They usually work together in intensive care units (ICUs) within a hospital.[1]
Scope
Patients are admitted to the intensive care unit if their medical needs are greater than what the general hospital ward can provide. Indications for the ICU include blood pressure support for cardiovascular instability (
There are two common ICU structures: closed and open.[5] In a closed unit, the intensivist takes on the primary role for all patients in the unit.[5] In an open ICU, the primary physician, who may or may not be an intensivist, can differ for each patient.[5][6] There is increasingly strong evidence that closed units provide better patient outcomes.[7][8] Patient management in intensive care differs between countries. Open units are the most common structure in the United States, but closed units are often found at large academic centers.[5] Intermediate structures that fall between open and closed units also exist.[5]
Types of intensive care units
Intensive care is usually provided in a specialized unit of a hospital called the intensive care unit (ICU) or critical care unit (CCU). Many hospitals also have designated intensive care areas for certain specialities of medicine.[9] The naming is not rigidly standardized, and types of units are dictated by the needs and available resources of each hospital. These include:
- coronary intensive care unit (CCU or sometimes CICU) for heart disease
- medical intensive care unit (MICU)
- surgical intensive care unit (SICU)
- pediatric intensive care unit (PICU)
- pediatric cardiac intensive care unit (PCICU)
- neuroscience critical care unit (NCCU)
- overnight intensive-recovery (OIR)
- shock/trauma intensive-care unit (STICU)
- neonatal intensive care unit (NICU)
- ICU in the emergency department (E-ICU)[10]
Medical studies suggest a relation between ICU volume and quality of care for mechanically ventilated patients.
History
The English nurse Florence Nightingale pioneered efforts to use a separate hospital area for critically injured patients. During the Crimean War in the 1850s, she introduced the practice of moving the sickest patients to the beds directly opposite the nursing station on each ward so that they could be monitored more closely.[14] In 1923, the American neurosurgeon Walter Dandy created a three-bed unit at the Johns Hopkins Hospital. In these units, specially trained nurses cared for critically ill postoperative neurosurgical patients.[15][14]
The Danish
In 1953, Ibsen set up what became the world's first intensive care unit in a converted student nurse classroom in Copenhagen Municipal Hospital. He provided one of the first accounts of the management of tetanus using neuromuscular-blocking drugs and controlled ventilation.[20] The following year, Ibsen was elected head of the department of anaesthesiology at that institution. He jointly authored the first known account of intensive care management principles in the journal Nordisk Medicin, with Tone Dahl Kvittingen from Norway.[21]
For a time in the early 1960s, it was not clear that specialized intensive care units were needed, so intensive care resources were brought to the room of the patient that needed the additional monitoring, care, and resources. It became rapidly evident, however, that a fixed location where intensive care resources and dedicated personnel were available provided better care than ad hoc provision of intensive care services spread throughout a hospital. In 1962, in the University of Pittsburgh, the first critical care residency was established in the United States. In 1970, the Society of Critical Care Medicine was formed.[22]
Monitoring
Monitoring refers to various tools and technologies used to obtain information about a patient's condition. These can include tests to evaluate blood flow and gas exchange in the body, or to assess the function of organs such as the heart and lungs.[23] Broadly, there are two common types of monitoring in the ICU: noninvasive and invasive.[1]
Noninvasive monitoring
Noninvasive monitoring does not require puncturing the skin and usually does not cause pain. These tools are more inexpensive, easier to perform, and faster to result.[1]
- Vital signs which includes heart rate, blood pressure, breathing rate, body temperature
- endotracheal tube in mechanically ventilatedpatients
- Echocardiogram to evaluate the function and structure of the heart
- Electroencephalography (EEG) to assess electrical activity of the brain
- Electrocardiogram to detect abnormal heart rhythms, electrolyte disturbances, and coronary blood flow
- Pulse oximetry for monitoring oxygen levels in the blood
- Thoracic electric bioimpedance (TEB) cardiography to monitor fluid status and heart function
- Ultrasound to evaluate internal structures including the heart, lungs, gallbladder, liver, kidneys, bladder, and blood vessels
Invasive monitoring
Invasive monitoring generally provides more accurate measurements, but these tests may require blood draws, puncturing the skin, and can be painful or uncomfortable.[1]
- Arterial line to directly monitor blood pressure and obtain arterial blood gas measurements
- Blood draws or venipucture to monitor various blood components as well as administer therapeutic treatments
- Intracranial pressure monitoring to assess pressures inside the skull and on the brain
- Intravesicular manometry (bladder pressure) measurements to assess for intra-abdominal pressure
- total parenteral nutrition
- Bronchoscopy to look at lungs and airways and sample fluid within the lungs
- Pulmonary artery catheter to monitor the function of the heart, blood volume, and tissue oxygenation
Procedures and treatments
Intensive care usually takes a system-by-system approach to treatment.
Airway management and anaesthesia
- Bag valve mask ventilation and laryngoscopy
- Induction and maintenance of endotracheal intubation to facilitate mechanical ventilation.
Cardiovascular
- Point of care echocardiography
- Central venous and arterial catherisation
- Temporary cardiac pacing catheters for atrial, ventricular, or dual-chamber pacing
- Intra-aortic balloon pumping to stabilize patients with cardiogenic shock
- Ventricular assist device to aid in the function of the left ventricle, commonly in patients with advanced heart failure
- Extracorporeal membranous oxygenation
Gastro-intestinal tract
- Feeding tube for artificial nutrition
- Nasogastric intubation can be used to deliver artificial nutrition, but can also be used to remove stomach and intestinal contents
- Peritoneal aspiration and lavage to sample fluid in the abdominal cavity
Renal
- acute kidney injury
Respiratory
- Mechanical ventilation to assist breathing and oxygenation through an endotracheal tube, tracheotomy (invasive) or mask, helmet (non-invasive).
- Thoracentesis or tube thoracostomy to remove fluid or air in the pleural cavity
- Percutaneous dilatational tracheostomyinsertion and ongoing management.
- Bronchoscopy including lavage.
Drugs
A wide array of
Physiotherapy and mobilization
Interventions such as early mobilization or exercises to improve muscle strength are sometimes suggested.[24][25]
Common complications in the ICU
Intensive care units are associated with increased risk of various complications that may lengthen a patient's hospitalization.[9] Common complications in the ICU include:
- Acute renal failure
- Catheter-associated bloodstream infection
- Catheter-associated urinary tract infection
- Delirium
- Gastrointestinal bleeding
- Pressure ulcer
- Venous thromboembolism
- Ventilator-associated pneumonia
- Ventilator-induced barotrauma
- Death
Training
ICU care requires more specialized patient care; this need has led to the use of a multidisciplinary team to provide care for patients.[4][1] Staffing between Intensive care units by country, hospital, unit, or institution.[5]
Medicine
Critical care medicine is an increasingly important medical specialty. Physicians with training in critical care medicine are referred to as intensivists.[26]
Most medical research has demonstrated that ICU care provided by intensivists produces better outcomes and more cost-effective care.
In Australia
In Australia, the training in intensive care medicine is through College of Intensive Care Medicine.
In Germany
In Germany, the German Society of Anaesthesiology and Intensive Care Medicine is a medical association of professionals in the anesthetics and intensive care fields. It was established in 1955 by members of the German Society of Surgery.
In the United Kingdom
In the UK, doctors can only enter intensive care medicine training after completing two foundation years and core training in either emergency medicine, anaesthetics, acute medicine or core medicine. Most trainees dual train with one of these specialties; however, it has recently become possible to train purely in intensive care medicine. It has also possible to train in sub-specialties of intensive care medicine including pre-hospital emergency medicine.
In the United States
In the United States, the specialty requires additional fellowship training for physicians having completed their primary residency training in internal medicine, pediatrics, anesthesiology, surgery or emergency medicine. US board certification in critical care medicine is available through all five specialty boards. Intensivists with a primary training in internal medicine sometimes pursue combined fellowship training in another subspecialty such as pulmonary medicine, cardiology, infectious disease, or nephrology. The American Society of Critical Care Medicine is a well-established multi professional society for practitioners working in the ICU including nurses, respiratory therapists, and physicians.
Intensive care physicians have some of the highest percentages of physician burnout among all medical specialties, at 48 percent. [28]
In South Africa
Intensive care training is provided as a fellowship and is awarded as a Sub-Specialty certificate of Critical Care (Cert. Critical Care) which is awarded by the Colleges of Medicine of South Africa. Candidates are eligible to enter sub specialty training after completing specialty training in Anaesthetics, Surgery, Internal Medicine, Obstetrics and Gynaecology, Paediatrics, Cardiothoracic surgery or Neurosurgery.
Training usually takes place over 2 years during which time candidates rotate through different ICU's (Medical, Surgical, Paediatric etc.)
Nursing
Nurses that work in the critical care setting are typically registered nurses.
Nurse practitioners and physician assistants
Nurse practitioners and physician assistants are other types of non-physician providers that care for patients in ICUs.[4] These providers have fewer years of in-school training, typically receive further clinical on the job education, and work as part of the team under the supervision of physicians.
Pharmacists
Critical care
Registered dietitians
Nutrition in intensive care units presents unique challenges due to changes in patient metabolism and physiology while critically ill.
Respiratory therapists
Respiratory therapists often work in intensive care units to monitor how well a patient is breathing.
Ethical and medicolegal issues
Economics
In general, it is the most expensive, technologically advanced and resource-intensive area of medical care. In the
See also
- Mechanical ventilation
- Extracorporeal membrane oxygenation
- Telemetry
- Chronic critical illness
- Critical care nursing
Notes
- ^ )
- ^ "About Intensive Care | the Faculty of Intensive Care Medicine". Archived from the original on 24 September 2021. Retrieved 9 March 2020.
- ^ "Critical Care Medicine Specialty Description". American Medical Association. Retrieved 24 October 2020.
- ^ )
- ^ )
- ^ OCLC 1118693260.)
{{cite book}}
: CS1 maint: location missing publisher (link) CS1 maint: others (link - PMID 9146680.
- PMID 10075049.
- ^ )
- PMID 29926792.
- S2CID 26611094. Archived from the original(PDF) on 29 July 2020.
- ^ Nolen-Hoeksema, Susan. "Neurodevelopmental and Neurocognitive Disorders." (Ab)normal Psychology. Sixth ed. New York City: McGraw-Hill Education, 2014. 314. Print.
- S2CID 24494855.
- ^ PMID 23514264.
- OCLC 1124935549.)
{{cite book}}
: CS1 maint: location missing publisher (link) CS1 maint: others (link - PMID 779520.
- PDF format).Intensive Care Medicine. Retrieved 2 October 2012.
- ^ US US2699163A, Engström, Carl Gunnar, "Respirator", issued 1951-06-25
- PMID 13190223.
- S2CID 40728057.
- PMID 13600704.
- ^ history reference: Brazilian Society of Critical Care SOBRATI Video: ICU History Historical photos
- PMID 28003877.
- PMID 29582429.
- PMID 25681407.
- ^ "What – or Who -- Is an Intensivist?". Healthcare Financial Management Association. Archived from the original on 27 September 2009.
- ^ "Association between Critical Care Physician Management and Patient Mortality in the Intensive Care Unit". Annals of Internal Medicine. 3 June 2008. Volume 148, Issue 11. pp. 801–809.
- ^ "Physician burnout: It's not you, it's your medical specialty". American Medical Association. 3 August 2018. Retrieved 7 July 2020.
- ^ )
- )
- ^ OCLC 1012122839.)
{{cite book}}
: CS1 maint: location missing publisher (link) CS1 maint: others (link - OCLC 85841308.
- S2CID 26028283.
- PMID 25654157.
References
- Intensive Care Medicine by Irwin and Rippe[permanent dead link]
- Civetta, Taylor, and Kirby's Critical Care
- The ICU Book by Marino
- Procedures and Techniques in Intensive Care Medicine by Irwin and Rippe[permanent dead link]
- Halpern NA, Pastores SM, Greenstein RJ (June 2004). "Critical care medicine in the United States 1985–2000: an analysis of bed numbers, use, and costs". S2CID 26028283..
- History references:
- Society of Critical Care Medicine
- Reynolds, H.N.; Rogove, H.; Bander, J.; McCambridge, M.; et al. (December 2011). "A working lexicon for the tele-intensive care unit: We need to define tele-intensive care unit to grow and understand it" (PDF). Telemedicine and e-Health. 17 (10): 773–783. PMID 22029748.
- Olson, Terrah; Brasel, Karen; Redmann, Andrew; Alexander, G.; Schwarze, Margaret (January 2013). "Surgeon-Reported Conflict With Intensivists About Postoperative Goals of Care". JAMA Surgery. 148 (1): 29–35. PMID 23324837.
Further reading
- Lois Reynolds; Wikidata Q29581786..
External links
- College of Intensive Care Medicine - Australia and New Zealand
- Australia and New Zealand Intensive Care Society
- Society of Critical Care Medicine
- Veterinary Emergency And Critical Care Society
- ESICM: European Society of Intensive Care Medicine
- ESPNIC: The society for paediatric and neonatal intensive care healthcare professionals in Europe
- UK Intensive Care Society
- Scottish Intensive Care Society
- Hong Kong Society of Critical Care Medicine
- Chinese Society of Critical Care Medicine
- Taiwan Society of Critical Care Medicine
- From Iron Lungs to Intensive Care, Royal Institution debate, February 2012