Special edition intensive care Medicine - Update in Anaesthesia

268 Pages·2012·6.44 MB·English

Volume 28 December 2012
Editor-in-chief: Bruce McCormick ISSN 1353-4882
Guest Editors: Fiona Martin
Nigel Hollister
Special edition
intensive care Medicine
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page 2 Update in Anaesthesia | www.anaesthesiologists.org
Update in
Anaesthesia
contents
4 editorial 133 Management of burns
The Global sepsis Alliance - fighting a global disease Nigel Hollister
Sebastian N Stehr and Konrad Reinhart 141 Management of drowning
Sarah Heikal and Colin Berry
6 editor’s notes s
Bruce McCormick SepSiS t
n
GeneRal pRincipleS 145 Management of sepsis with limited resources
e
7 Intensive care medicine in resource-limited settings: a Kate Stephens
t
general overview 156 Abdominal compartment syndrome
n
Martin W Dünser William English
o
11 Systematic assessment of an ICU patient
MicRobioloGy
Sebastian Brown, Sophia Bratanow and Rebecca Appelboam c
160 ‘Bugs and drugs’ in the Intensive Care Unit
18 Intensive care medicine in rural sub-Saharan Africa - who Simantini Jog and Marina Morgan
to admit?
caRdiovaSculaR
RM Towey and John Bosco Anyai
169 Inotropes and vasopressors in critical care
22 Identifying critically ill patients - Triage, Early Warning
Hannah Dodwell and Bruce McCormick
Scores and Rapid Response Teams
177 Management of cardiac arrest - review of the 2012
Tim baker, Jamie Rylance and David Konrad
European Resuscitation Guidelines
27 Critical care where there is no ICU: Basic management of
Paul Margetts
critically ill patients in a low income country
Tim Baker and Jamie Rylance ReSpiRatoRy
183 Acute respiratory distress syndrome (ARDS)
MonitoRinG
David Lacquiere
32 Monitoring in ICU - ECG, pulse oximetry and capnography
188 Hospital-acquired pneumonia
Ben Gupta
Yvonne Louise Bramma and radha Sundaram
37 Invasive blood pressure monitoring
192 An introduction to mechanical ventilation
Ben Gupta
Fran O’Higgins and Adrian Clarke
43 Central venous cannulation
199 Tracheostomy
Will Key, Mike Duffy and Graham Hocking
Rakesh Bhandary and Niraj Niranjan
51 Cardiac output monitoring
Thomas Lawson and Andrew Hutton Renal
207 Acute kidney injury - diagnosis, management and prevention
GeneRal caRe
Clare Attwood and Brett Cullis
59 Acid-base disorders in critical care
215 Renal replacement therapy in critical care
Alex Grice
Andrew Baker and Richard Green
67 Delirium in critical care
223 Peritoneal dialysis in acute kidney injury
David Connor and William English
Brett Cullis
74 Sedation in intensive care patients
Gavin Werrett neuRoMuSculaR diSeaSe
79 Nutrition in the critically ill 228 Neurological causes of muscle weakness in the Intensive
Sophia Bratanow and Sebastian Brown Care Unit
Todd Guest
88 Evidence-based medicine in critical care
Mark Davidson 233 Tetanus
Raymond Towey
tRauMa
240 Brainstem death
95 Management of major trauma
Niraj Niranjan and Mike Duffy
Lara Herbert and Ruth Barker
243 Cultural issues in end-of-life care
107 Management of head injuries
Sara-Catrin Cook and Carol Peden
Bilal Ali and Stephen Drage
112 Acute cervical spine injures in adults: initial management MiScellaneouS
Pete Ford and Abrie Theron 247 Diabetic ketoacidosis
119 Thoracic trauma Claire Preedy and William English
Anil Hormis and Joanne Stone 253 Emergency management of poisoning
125 Guidelines for management of massive blood loss in Sarah Heikal, Andrew Appelboam and Rebecca Appelboam
trauma 261 Management of snake envenomation
Srikantha L Rao and Fiona Martin Shashi Kiran and T A Senthilnathan
130 Rhabdomyolysis
Michelle Barnard
Update in Anaesthesia | www.anaesthesiologists.org page 3
Update in
Anaesthesia
Guest editorial
the Global Sepsis alliance – fighting a global disease
Only in the past thirty years has sepsis been recognized
as a very common disease of global proportions and Sepsis is a life threatening condition that arises
l
a impact. Initially underdiagnosed and unrecognized, when the body’s response to an infection
i it is now accepted that sepsis, a clinical syndrome injures its own tissues and organs. Sepsis may
r
o defined by the presence of both infection and a lead to shock, multiple organ failure, and death,
t systemic inflammatory response,1 is most probably especially if not recognized early and treated
i one of the leading causes of death in the world.2 promptly. Sepsis remains the primary cause of
d
727,000 patients were hospitalized with a primary death from infection despite advances in modern
e
diagnosis of septicaemia or sepsis in the United States medicine, including vaccines, antibiotics, and
in 2008, more than double the number of patients acute care. Millions of people die of sepsis every
documented in 2000.3 In-hospital deaths were year worldwide.
more than eight times more likely in patients with a
diagnosis of septicaemia or sepsis compared to other Large scale studies are necessary to find out more
diagnoses.3 These estimates concern an environment about possible interventions to reduce sepsis-related
of a developed, modern intensive care setting. There is morbidity and mortality. A major goal of the GSA
very little data available for the developing world, where is to assist societies and initiatives in the process of
the majority of worldwide deaths related to sepsis are developing proposals for experiments, trials, projects
to be expected due to the prevalence of HIV/AIDS, and programs in support of researchers, caregivers and
malaria and maternal sepsis. It has been proven that the public, especially in securing funding to implement
the introduction of evidence-based guidelines focussing such efforts. The GSA is to be empowered to easily
on early recognition, emergent antibiotic treatment identify and access resources and people of common
and application of fluids and vasopressors can reduce purpose and intent within and without the scientific
sepsis-related mortality.4 It is unclear to what extent community.
these interventions can be translated to a developing
The 2005 World Health Organisation Health global
world setting.5
report on global child death considers that 80% of
A multitude of local, national and international global child deaths are related to severe infections
organisations and societies dedicated to sepsis have associated with pneumonia, malaria, measles, neonatal
developed over the past years. The Global Sepsis sepsis, and diarrhoea.6 One exemplary project supported
Alliance (GSA) was launched in September 2010 as by the GSA is the development and implementation of
part of a Merinoff Symposium of the Feinstein Institute sepsis demonstration projects in the poor districts of
for Medical Research on Long Island, to take on sepsis Ugandan, both urban and rural, in collaboration with
as a global problem. The GSA was founded by the the Ministry of Health, Makerere University College
World Federation of Societies of Intensive and Critical of Health Sciences, Mbarara University of Science and
Care Medicine (WFSICCM), the World Federation Technology and the Centre for International Child
of Pediatric Intensive and Critical Care Societies Health, University of British Columbia. The GSA
(WFPICCS), the International Sepsis Forum (ISF), the will employ its contacts to regionally and globally
Sepsis Alliance USA (SA) and the World Federation of disseminate the initiative’s experiences, findings and
Critical Care Nurses (WFCCM) to coordinate global lessons learned. The GSA will focus on addressing with
efforts against sepsis and to speak with one voice. In equal commitment and vigour the needs of both adults
Sebastian N Stehr the meantime, the member organisations of the GSA and children in the developed and developing world.
represent over 600,000 health care professionals from
The GSA urges the medical community to recognize
Konrad Reinhart
more than 70 countries (Table 1). The GSA has set
sepsis as a medical emergency, requiring the
Chairman of the Global
out to “Speak in One Voice” offering consistent, easily
administration of fluids, antibiotics and other
Sepsis Alliance
understood messaging to governments, philanthropies
appropriate treatments of infection within one hour
Department of
and the public.
of first suspecting a case of sepsis. This is also possible
Anesthesiology and
in regions without modern intensive care units, using
Intensive Care Medicine The GSA has set goals to provide opportunities
a less sophisticated approach.7
Friedrich-Schiller-University supportive of global interaction and defined output. As
Jena a first step, the GSA has developed a definition of sepsis In conclusion, the global burden of sepsis is high and
Germany that facilitates communication with the lay public: is increasing, especially in the developing world. The
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Update in
Anaesthesia
table 1. Membership of the Global Sepsis Alliance. use of current evidence-based knowledge must be applied to reduce
the worldwide high sepsis mortality rate. Healthcare professionals and
Membership of the Global Sepsis alliance
laypersons must be taught that sepsis is an emergency requiring urgent
treatment. The GSA will focus on programs to better understand
Founding organizations
that sepsis is an emergency and to foster a greater understanding
International Sepsis Forum (ISF)
of the medical burden of sepsis among the public and is planning
Sepsis Alliance (SA)
a World Sepsis Day for 2012. The GSA encourages all concerned
World Federation of Pediatric Intensive and Critical Care groups and societies to learn from each other and to join forces in
Societies (WFPICCS) the fight against sepsis at a global level and to become a member of
World Federation of Societies of Intensive and CriticalCare the GSA. More information is available on the GSA website at www.
Medicine (WFSICCM) globalsepsisalliance.com.
World Federation of Critical Care Nurses (WFCCN)
ReFeRenceS
Committed organizations 1. Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM, Jaeschke R, et
American Thoracic Society (ATS) al. Surviving Sepsis Campaign: international guidelines for
management of severe sepsis and septic shock: 2008. In: Critical Care
Australia and New Zealand Intensive Care Society (ANZICS)
Medicine 2008. p 296–327.
Belize Medical and Dental Association
2. Marshall JC, Reinhart K. The Global Sepsis Alliance: building new
Centre for International Child Health
collaborations to confront an under-recognized threat. Surg Infect
Chilean Society of Critical Care
(Larchmt) 2011; 12: 1–2.
Chinese Society of Critical Care Medicine
3. Hall MJ, Wiliams SN, DeFrances CJ, Golosinsky A. Inpatient Care for
Dutch Meningitis Initiative
Septicemia or Sepsis: A Challenge for Patients and Hospitals [Internet].
Emirates Intensive Care Society NCHS Data Brief. [cited 2011 Nov. 9]; 62(June 2011). Available from:
German Sepsis Society and German Sepsis Aid http://www.cdc.gov/nchs/data/databriefs/db62.pdf.
Gruppo italiano per la Valutazione degli interventi in Terapia 4. Levy MM, Dellinger RP, Townsend SR, Linde-Zwirble WT, Marshall JC,
Intensiva (GiViTI) Bion J, et al. The Surviving Sepsis Campaign: results of an international
Hellenic Sepsis Study Group guideline-based performance improvement program targeting
severe sepsis. Intensive Care Medicine 2010; 36: 222–31.
International Forum for Acute Care Trialists (InFACT)
International Pan Arab Critical Care Medicine Society 5. Cheng AC, West TE, Limmathurotsakul D, Peacock SJ. Strategies to
Reduce Mortality from Bacterial Sepsis in Adults in Developing
Latin American Sepsis Institute
Countries. PLoS Med 2008; 5: e175.
Maventy Health International
6. Bryce J, Boschi-Pinto C, Shibuya K, Black RE, WHO Child Health
Society of Critical Care Medicine
Epidemiology Reference Group. WHO estimates of the causes of
Spanish Edusepsis Network
death in children. Lancet 2005; 365: 1147–52.
Surgical Infection Society (SIS)
7. Kissoon N, Carcillo JA, Espinosa V, Argent A, Devictor D, Madden M, et
Survive Sepsis
al. World Federation of Pediatric Intensive Care and Critical Care
United Kingdom Sepsis Trust Societies: Global Sepsis Initiative*. Pediatric Critical Care Medicine 2011;
12: 494–503.
Update in Anaesthesia | www.anaesthesiologists.org page 5
Update in
Anaesthesia
editor’s notes
Dear Readers, appropriate coverage of the topic for areas where some level of more
advanced equipment may be available. In many parts of the world,
Welcome to this Special Edition of Update in Anaesthesia, which
health centres that are geographically close to each other may vary
focuses on Intensive Care Medicine. This specialty has developed
greatly in their resources, due largely to the influence of alternative
greatly over the last 30 years, however development of dedicated
funding streams from non-government organisations.
intensive care units (ICUs) in more poorly resourced countries has
only come about in the last few years. We think of an ICU as a I hope that this edition is useful. I would appreciate your feedback
location in the hospital where the sickest patients are admitted for at [email protected]. The articles do not cover this subject
more invasive monitoring and more aggressive organ support and fully and suggestions for further ICM topics would be welcomed.
therapy. Inherently these monitors and treatments incur far higher This edition is available, along with the full back catalogue of Update
costs than standard ward care, making them unachievable in many in Anaesthesia at http://update.anaesthesiologists.org
settings.
Bruce McCormick
However, equipment is not the major factor that sets the ICU or
high dependency unit (HDU) apart from the other wards of a Editor-in-chief
hospital; it is the expertise and numbers of the ICU staff that Consultant in Anaesthesia and Intensive Care Medicine
confers the most dramatic advantage in providing effective care for Exeter, UK
the critically ill. Nursing staff numbers, and therefore the nurse to
patient ratio, vary starkly between the general wards (around one
to sixty in the description of a Ugandan ICU by Towey and Anyai,
update team
on page 16 of this edition of Update) and the ICU (ideally 1:1, but
commonly 1:4 or 1:6). In addition it is the quality of training and
Editor-in-chief
experience of these nursing staff that has a major impact on patient
Bruce McCormick (UK)
care, particularly where staff morale allows good retention of staff
and longevity of careers in the ICU. Guest Editors
Nigel Hollister (UK)
In addition to good nursing care, close attention to the detail of
basic good medical care by trained and experienced clinical officers Fiona Martin (UK)
and doctors, probably has a far greater impact on patient outcome
Editorial Board
than use of expensive, invasive equipment. In fact there are few
interventions in ICU for which the evidence remains relatively Douglas Bacon (USA)
unequivocal, examples being nursing patients in the semi-recumbent Aboudoul-Fataou Ouro Bang’na (Togo)
position (30 degrees head up) to decrease the incidence of ventilator
Martin Chobli (Benin)
associated pneumonia and administration of antibiotics to patients
Gustavo Elena (Argentina)
with sepsis within one hour or presentation. Therapies such as steroids
and activated protein C for septic shock, despite encouraging early SS Harsoor (India)
randomised control studies, have now been proven to be ineffective Kazuyoshi Hirota (Japan)
or harmful. Many of the more technical strategies for providing
David Pescod (Australia)
advanced respiratory support to patients with intractable hypoxia,
Jeanette Thirlwell (Australia)
such as extra-corporeal membrane oxygenation and high frequency
oscillation ventilation, have very little supporting evidence. Isabeau Walker (UK)
Zhanggang Xue (China)
So we are left in a situation where timely basic interventions are
likely to bring about the greatest improvements in mortality and Jing Zhao (China)
morbidity of critically ill patients, manoeuvres such as effective
Chief Illustrator
airway management and haemodynamic resuscitation in trauma,
Dave Wilkinson (UK)
early antibiotics and surgical source control in sepsis. These strategies
are available in most healthcare settings around the world.
Typesetting
This edition of Update in Anaesthesia attempts to provide an overview Angie Jones, Sumographics (UK)
of the essential aspects of care of the critically ill and critically
injured, with particular focus on practices that are most relevant and Printing
achievable in poor resource settings. For most topics in our speciality COS Printers Pte Ltd (Singapore)
we have tried to achieve a balance between making the text relevant to
workers where ‘high-tech’ equipment is not available and achieving
page 6 Update in Anaesthesia | www.anaesthesiologists.org
Update in
Anaesthesia
s
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intensive care medicine in resource-limited settings:
i
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a general overview n
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Martin W Dünser p

Correspondence Email: [email protected] l
a
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e
WHat iS intenSive caRe Medicine? In countries like Bangladesh, India and Nepal, there has n
recently been an important increase in the availability of
Intensive or critical care medicine refers to the e
intensive care units, although shortage in staffing, lack
medical specialty which focuses on the management G
of basic equipment, poor maintenance of equipment
of critically ill patients. Critical illness describes a
and interrupted supplies often pose major challenges.
general state which may arise from various medical
In addition, the medical profession in less developed
pathologies (e.g. trauma, infection, acute coronary
countries is, in general, not set up to provide formal
syndrome, stroke etc.) and leads to the impairment Summary
training in intensive care medicine. Knowledge about
of vital (consciousness, circulation or respiration) or
important recent progress in the field is frequently This introductory article
single organ functions (e.g. kidney or liver function). gives an overview of
absent. These factors inevitably result in a lack of
Furthermore, intensive care includes the care of patients intensive care medicine in
recognition of intensive care medicine as a medical
after major surgery or the observation of patients in developing countries and
specialty in resource-poor settings. As a consequence,
whom critical illness may rapidly occur. contrasts its development
disproportionately high mortality rates have been
with high-income countries.
intenSive caRe Medicine in ReSouRce- reported for selected critical illnesses in developing The second part of this
countries.4 manuscript aims to give the
pooR SettinGS
reader a general overview
In Western countries, the first intensive care units diFFeRenceS in intenSive caRe Medicine of the basic aspects and
(dedicated hospital wards where intensive care medicine betWeen HiGH incoMe and ReSouRce- requirements of ICUs and
is practiced and critically ill patients are cared for) were pooR SettinGS intensive care medicine in
established in the 1950s and 1960s following the last resource-poor settings.
Intensive care medicine between Western and less
European polio epidemics.1 Since then the number
developed countries not only differs in equipment
of intensive care units (ICUs) has grown steadily and
and material availability, but also in the patient
intensive care medicine has gained importance as a
populations treated in the ICU.5 In less developed
medical specialty in its own right. The majority of acute
countries critically ill patients admitted to the ICU
care hospitals in high-income countries now run one or
are characteristically younger, suffering from less
more ICUs. The most frequent pathologies leading to
premorbid conditions. The underlying diseases
ICU admission in Western countries are cardiovascular
leading to ICU admission in resource-poor areas
diseases, major surgery, sepsis and respiratory failure.
differ geographically from those seen in high income
Although the first ICUs were introduced to select countries. While in Northern developing countries (e.g.
resource-poor settings shortly after intensive care central Asian countries) ICU admission diagnoses are
medicine started to develop, the majority of critically ill similar to those reported from high income countries,
patients in less developed countries, harboring around tropical and infectious diseases are among the leading Martin W Dünser MD DESA
two thirds of the world population, still do not have causes of critical illness in developing countries in Global Intensive Care
access to intensive care.2 Few data exist on the current South Asia, South America and Africa. Trauma and Working Group of the
state of intensive care medicine in less developed sepsis are far more common in ICUs of developing than European Society of
countries, but there seems to be wide variability in Western countries. Disease severity at ICU admission Intensive Care Medicine.
the availability of ICUs in these countries, ranging is typically higher in resource-poor settings, while the Department of
from non-existent to sophisticated centres in selected number of interventions and procedures performed Anesthesiology,
private hospitals catering for a few privileged patients. is smaller compared to critically ill patients admitted Perioperative Medicine
Recent data from the Republic of Zambia revealed that to ICUs in high income countries. Irrespective of the and General Intensive Care
only 29 ICU beds exist for the entire country of 12.9 ICU admission diagnosis, mortality rates of critically ill Medicine, Salzburg General
million people and only 7% of hospitals providing patients are consistently higher in less developed than Hospital and Paracelsus
surgical services run an ICU. Even in those hospitals in high income countries.5 Private Medical University
with ICUs, basic equipment is lacking and an oxygen MüllnerHauptstrasse 48
supply is only inconsistently available.3 Similar data icu StaFFinG 5020 Salzburg
were reported from other African or Asian regions. An ICU needs the presence of well trained and Austria
Update in Anaesthesia | www.anaesthesiologists.org page 7
experienced ICU workers 24-hours-a-day, 7-days-a-week. An ideal conStRuctional aSpectS oF an icu
ICU team consists of nurses, specially trained in intensive care
Even though intensive care medicine can be supplied under several
medicine, one or more intensivists (physicians specialized in providing
circumstances and at various locations, an ICU in a resource-poor
intensive care medicine) and a variable number of nurse assistants,
setting has certain constructional requirements. Non-leaking roofs,
technicians and cleaners. In many resource-poor settings, the role of the
closable windows/doors, solid walls and, whenever necessary, a
intensivist is taken over by a nurse anaesthetist or an anaesthetic clinical
functional heating system must be available to protect patients and
officer. This is a practicable and legitimate policy since maintenance
staff from adverse climate influences. Floors and walls should be easily
and restoration of vital functions is one of the key fields of anaesthesia.
washable to allow effective cleaning. Light and a stable electricity
If the intensivist is not a medical doctor, it is advisable that a physician
supply are further indispensable prerequisites to run an ICU. Stable
is available to assist in the care of the critically ill patient’s underlying
electricity supply, on the one hand, includes the availability of a power
disease. Ideally, the intensivist in charge should be a physician specially
generator (e.g. driven by gasoline or diesel), providing electricity in
trained in intensive care medicine. In some Western countries (e.g.
case of power cuts. On the other hand, in many resource-poor settings,
the United Kingdom), specialized postgraduate training programs for
voltage stabilizers need to be placed in the main electrical line supplying
intensive care medicine exist. In addition, diplomas in intensive care
the ICU, in order to prevent voltage peaks that may damage delicate
medicine can be taken from international intensive care societies (e.g.
medical apparatus such as mechanical ventilators or patient monitors.
the European Society of Intensive Care Medicine).
Due to the wide-ranging lack of health care personnel and qualified
staff in many resource-poor settings, the anaesthetist/physician
5
caring for the ICU often has to fulfill additional medical duties in
the operation theatre or hospital, particularly at night and during
weekends. This frequently leaves the ICU unattended by an intensivist
1
and places more responsibility on the ICU nurses, making them the
key players of the ICU team. Trust and good communication with
the intensivist in charge, as well as continuous education, adequate
4
training and a strong team spirit, are of outstanding importance for
ICU nurses in resource-poor settings.
oRGaniZational aSpectS oF an icu 3
An ICU can be organized in different ways. Larger hospitals in
particular often run specialized ICUs caring for critically ill patients 2
with selected diseases; for example surgical, pediatric, neurosurgical,
Figure 1. Intensive care unit in a rural African hospital - 1, patient monitor;
cardiac, medical or burns ICUs. Although this may have some
2, suction machine; 3, oxygen concentrator; 4, mechanical ventilator; 5,
benefits for certain patient populations, recent data indicate that
mosquito net.
multidisciplinary ICUs caring for patients with different pathologies
may result in better care. In any case, it is important to understand that
Running water with a constant supply of soap is essential to reduce
caring for a critically ill patient, irrespective of the underlying disease,
cross-infection between critically ill patients. In areas where malaria
must include an interdisciplinary approach, involving integration
and other insect-transmitted infectious diseases are endemic, mosquito
of physicians from other medical specialties such as neurologists,
nets should be available for each ICU bed to protect patients from
surgeons or pediatricians. Mutual respect is a prerequisite for fruitful
insect bites during evening and night times (Figure 1). Air filtering
interdisciplinary communication.
and room climatization are not essential, but can greatly help to
In a closed ICU one or more intensivist is principally responsible maintain clean air and adjust room temperatures and air pressure
for the care of all patients admitted to the ICU. This organizational to patient needs. Although no scientific data have so far proven that
structure is in contrast to the open ICU where different physicians, who isolation of patients with resistant bacteria, such as methicillin-resistant
are not continuously present in the ICU, care for single critically ill Staphylococcus aureus, can reduce transmission of these bacteria to
patients. Organization of ICUs as closed units, including the presence other patients, an ICU should include a room to isolate patients.
of a an intensivist, has been shown to result in lower mortality, less For certain infectious diseases, such as open pulmonary tuberculosis
complications, a reduced length of ICU stay and lower costs, when or certain viral haemorrhagic fevers, isolation is obligatory. When
compared to open ICUs.6 If hospitals are too small to implement a 24- spatial isolation is required, the patient should not be in isolation
hour intensivist service, telemedical assistance by external intensivists from medical and nursing care. The nurse base, an integral part of
may be used to support decision making and patient care.7 Although the ICU, should be placed centrally and allow full sight on as many
most reports on intensive care telemedicine originate from high- ICU beds as possible (Figure 2).
income countries (the United States and Australia), personal experience
oXyGen, pReSSuRiZed aiR and Suction
of the author suggests that regular (e.g. weekly) telemedical counseling
by experienced intensivists can be a valuable tool to improve patient One of the most important drugs required in the ICU is oxygen.
care in ICUs in resource-limited areas. Oxygen can be stored and supplied in various ways. Oxygen
page 8 Update in Anaesthesia | www.anaesthesiologists.org
Figure 2. View from the nurse base of a Mongolian ICU. Figure 3. Air compressor supplying the pressurized air system of a
Mongolian ICU, with the pressure regulator indicated by the white arrow.
concentrators provide 90-100% oxygen but rely on a constant crucial to consider that no apparatus can replace an alert ICU worker
electricity supply and usually do not provide oxygen flows higher at the bedside. Nonetheless, certain technical devices are required to
than 4-6L.min-1. While this is sufficient to treat neonates and infants support the work of the ICU staff. These typically include patient
with respiratory insufficiency, in many cases it is inadequate to monitors, suction machines and mechanical ventilators. While patient
oxygenate larger children or adults with respiratory failure. In contrast, monitors measuring ECG, respiratory rate, arterial blood pressure and
oxygen cylinders can provide pure oxygen at high flow rates and are oxygen saturation should be available at each bed, suction machines
independent of electricity supply, but need to be replenished at regular and mechanical ventilators can be used specifically for patients in
intervals. This must be addressed in advance before the last cylinder need of these devices. The technical aspects of mechanical ventilators
has emptied, leaving the patient with respiratory distress without must be considered, because the majority of available ventilators
oxygen. Central oxygen systems are the most efficient and convenient depend on a dual supply of pressurized oxygen and air. In ICUs where
way to store and supply ICUs with oxygen. The source of oxygen of neither pressurized air nor adequate stores of pressurized oxygen are
a central oxygen system can either be a special oxygen tank storing available, only ventilators with internal air compressors together with
oxygen at low temperatures, or a bank of oxygen cylinders. Both of an external oxygen source (e.g. from an oxygen concentrator or an
these require regular maintenance and replenishment. The tubing of oxygen cylinder) can be used.
the pressurized oxygen system must consist of a non-oxidizing material,
typically copper. In countries where no professional companies offer Infusion and syringe pumps allow drugs and fluids to be administered
installation of medical air systems, refrigeration engineers usually at exact rates and dosages, but, in the clinical practice of resource-
have sufficient experience in installing copper/pressurized gas lines. poor settings, may well be replaced by mechanical drop regulators
or close clinical surveillance by a nurse. Any device not depending
Pressurized air, used to run mechanical ventilators, can similarly
on electricity increases patient safety during power cuts, particularly
be administered either by direct connection of a compressor to the
when vital drugs (e.g. catecholamines) are infused. Despite being a life-
mechanical ventilator or preferably by connecting a compressor to
saving intervention, renal replacement therapy in patients with acute
a central air system, providing pressurized air through single outlets
kidney failure is usually unavailable in resource-poor settings. Given
at each ICU bed. Although specific medical air compressors exist,
that neither intermittent hemodialysis nor continuous hemofiltration
oil-free industrial compressors, with a pressure regulator as well as
is superior in terms of patient survival, and that hemofiltration is
additional air filters, provide comparable air qualities. These are more
more time and resource-consuming, intermittent hemodialysis is
easily affordable in resource-poor settings (Figure 3). Where oil-free
the technique of choice to treat patients with acute kidney failure in
compressors are available air filters need to be placed in the air lines
resource-poor settings. Although data on the use of peritoneal dialysis
and before air enters the ventilator. Although oil spilling into the
in critically ill patients with acute kidney failure are conflicting,
patient’s respiratory system is the by far most relevant danger, more
peritoneal dialysis may be an option if local experience is available.
frequent complications are acute blockade of line or air filters in the
ventilators. Central suction units may be connected to the pressurized Similarly, a basic set of essential disposable materials, drugs and
air system, but usually depend on special suction generators, which laboratory tests need to be available to adequately and safely care for
can be cumbersome to find and install in resource-limited areas. critically ill patients. These sets usually do not need to include high-
end materials or a large variety of drugs or tests, but should focus on
baSic ReSouRce ReQuiReMentS oF an icu
the basic needs of critically ill patients treated in the respective ICU.
Although intensive care medicine, above most other medical Furthermore, small numbers of essential materials, drugs and tests
specialties, relies on technical devices and material resources, it is warrants expert use by the ICU staff and facilitates stock maintenance.
Update in Anaesthesia | www.anaesthesiologists.org page 9
tHe icu’S place in a ReSouRce-pooR HoSpital table 1. Ten basic principles of intensive care medicine.
Intensive care medicine is an integrative medical specialty, requiring
1 No medical apparatus can replace the presence of an ICU
close cooperation with several other medical disciplines and technical
worker at the bedside.
services (e.g. laboratory services, blood bank etc.) in the hospital.
Therefore, to assure adequate and efficient care of critically ill patients, 2 No diagnostic test can replace a thorough patient history,
other medical departments and hospital services need to be prepared chart review or systematic clinical examination.
and trained to manage the needs of critically ill patients.2,4 3 Supportive therapy is life-saving, challenging and may distract
the intensivist’s attention from searching for the underlying cause
Since ICUs in resource-poor settings are either non-existent or have
of critical illness. Always try to identify why a critically
only recently been established, acceptance of ICU services among
ill patient is sick and do everything to treat this condition.
colleagues from other medical specialties (who have so far cared for
4 Always ask why a patient is deteriorating or fails to improve.
critically ill patients on the hospital ward) is a frequent problem.
Never accept or explain treatment failures simply by disease
After establishing an ICU in a resource-poor hospital, referral and
severity.
admission rates are often low. If patients are admitted this typically
occurs at a pre-terminal stage, where ICU interventions may fail to 5 Do not over-sedate. Only sedate agitated patients or those
safe the patient’s life. This can lead to a perception amongst ward with certain diseases (intracranial hypertension, acute lung or
circulatory failure).
staff and relatives that patients are transferred to the ICU to die.
Integration of ward physicians into ICU care (e.g. during daily rounds 6 Do not overhydrate patients. Although fluid resuscitation can
or regular discussions at the bedside), together with education of the safe lives in the acute phase, indiscriminate infusion of fluids at
hospital staff about when to admit patients to the ICU are ways to later stages leads to complications (e.g. sepsis), prolongs ICU
increase acceptance of newly established ICU services in resource- stay and increases mortality.
poor hospitals. 7 Do no harm! Be aware that every intervention and drug applied
in the ICU carries the potential to harm the patient.
When ICU services are well-established and accepted, unavailability
of ICU beds is a far greater problem. ICU bed capacities need to be 8 As soon as the patient has stabilized do everything to reduce
coordinated with the emergency department and the operation theatre invasive support.
at regular intervals each day. From a practical standpoint, ICUs should 9 Always consider the therapeutic consequence before
always have the capacity to admit unplanned critically ill patients. This performing diagnostic tests (e.g. imaging studies).
can be organized by leaving one ICU bed in the hospital unoccupied
10 Do not indiscriminately order laboratory tests but only measure
or having the facility to discharge one patient rapidly to an appropriate
these values where relevant and pathologic information can
hospital ward.
be expected.
intenSive caRe Medicine ‘WitHout WallS’
Provision of intensive care medicine is not only restricted to the ICU. ReFeRenceS
In order to prevent patients being admitted too late, after they have 1. Berthelsen PG, Cronqvist M. The first intensive care unit in the world:
Copenhagen 1953. Acta Anaesthesiol Scand 2003; 47: 1190-5.
developed irreversible shock or organ failure, the intensivist can play
a valuable role in assessing patients before ICU admission (e.g. in the 2. Baker T. Critical care in low-income countries. Trop Med Int Health
operation theatre or the emergency department) or after ICU discharge 2009; 14: 143-8.
(post-ICU review). In several hospitals, intensivists play a key role in
3. Jochberger S, Ismailova F, Lederer W et al. Anesthesia and its allied
resuscitation teams or medical emergency teams. The function of these disciplines in the developing world: a nationwide survey of the
teams within a hospital is described in a later article. Implementation Republic of Zambia. Anesth Analg 2008; 106: 942-8.
of medical emergency teams in hospitals of high-income countries
4. Dünser MW, Bataar O, Tsenddorj G et al. Differences in critical care
reduced the rates of unexpected cardiac arrests on non-ICU wards.8
practice between an industrialized and a developing country. Wien
In addition to providing resuscitation and emergency care, intensivists
Klin Wochenschr 2008; 120: 600-7.
may further assist physicians from other medical specialties with certain
5. Dünser MW, Baelani I, Ganbold L. A review and analysis of intensive
clinical problems (e.g. prescription of parenteral/enteral nutrition,
care medicine in the least developed countries. Crit Care Med 2006;
provision of palliative care, cannulation of central vessels or assessment
34: 1234-42.
of surgical and anaesthetic risks).
6. Topeli A, Laghi F, Tobin MJ. Effect of closed unit policy and appointing
concluSion an intensivist in a developing country. Crit Care Med 2005; 33: 299-
306.
Intensive care medicine is a comparatively young medical specialty
which has grown rapidly to become an essential component of 7. Lilly CM, Cody S, Zhao H et al. Hospital mortality, length of stay, and
modern hospitals. Many hospitals in resource-poor settings do not preventable complications among critically ill patients before and
run ICUs and critically ill patients frequently receive suboptimal care after tele-ICU reengineering of critical care processes.
JAMA 2011; 305: 2175-83.
with unacceptable levels of mortality. When implementing intensive
care medicine in resource-poor settings several staff, constructional, 8. Jones DA, DeVita MA, Bellomo R. Rapid Response Teams. N Engl J Med
organizational and resource aspects need to be considered. 2011; 365: 139-46.
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