Intensive care medicine
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Intensive Care Medicine or critical care medicine is a branch of medicine concerned with the provision of life support or organ support systems in patients who are critically ill who usually also require intensive monitoring.
Patients requiring intensive care usually require support for hemodynamic instability (hypotension), for airway or respiratory compromise and/or renal failure, and often all three. Patients admitted to the intensive care unit not requiring support for the above are usually admitted for intensive/invasive monitoring, usually after major surgery.
Intensive care is usually only offered to those whose condition is potentially reversible and who have a good chance of surviving with intensive care support. Since the critically ill are close to dying the outcome of this intervention is difficult to predict. Many patients therefore still die in the Intensive Care Unit. A prime requisite for admission to an Intensive Care Unit is that the underlying condition can be overcome. Therefore treatment is merely meant to win time in which the acute affliction can be resolved.
Medical studies suggest a relation between intensive care unit (ICU) volume and quality of care for mechanically ventilated patients. [1] After adjustment for severity of illness, demographic variables, and characteristics of the ICUs (including staffing by intensivists), higher ICU volume was significantly associated with lower ICU and hospital mortality rates. For example, adjusted ICU mortality (for a patient at average predicted risk for ICU death) was 21.2% in hospitals with 87 to 150 mechanically ventilated patients annually, and 14.5% in hospitals with 401 to 617 mechanically ventilated patients annually. Hospitals with intermediate numbers of patients had outcomes between these extremes.
It is generally the most expensive, high technology and resource intensive area of medical care. In the United States estimates of the 2000 expenditure for critical care medicine ranged from US$15-55 billion accounting for about 0.5% of GDP and about 13% of national health care expenditure (Halpern, 2004).
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[edit] Organ Systems
Intensive care usually takes a system by system approach to treatment, rather than the SOAP (subjective, objective, analysis, plan) approach of high dependency care. The nine key systems (see below) are each considered on an observation-intervention-impression basis to produce a daily plan. As well as the key systems Intensive care treatment also raises other issues including psychological health, pressure points, mobilisation and physiotherapy, and secondary infections.
The nine key IC systems are (alphabetically): cardiovascular system, central nervous system, endocrine system, gastro-intestinal tract (and nutritional condition), hematology, microbiology (including sepsis status), peripheries (and skin), renal (and metabolic), respiratory system.
The provision of intensive care is generally administered 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, such as the Coronary Care Unit (CCU) for heart disease, Medical Intensive Care Unit (MICU), Surgical Intensive Care Unit (SICU), Pediatric Intensive Care Unit (PICU), Neuroscience Critical Care (NCCU), Overnight Intensive Recovery (OIR), Neuro/Neonatal Intensive Care Unit (NICU), Neonatal Intensive Care Unit (NICU), and other units, as dictated by the needs and available resources of each hospital. The naming is not rigidly standardized. For a time in the early 1960s it was not clear that specialized intensive care units were needed and intensive care resources (see below) were brought to the room of the patient who needed the additional nursing care and resources. It became rapidly evident, though, that a fixed location where intensive care resources and personnel were available provided better care than ad hoc provision of intensive care services spread throughout a hospital.
[edit] Equipment and Systems
Common equipment in an intensive care unit (ICU) includes mechanical ventilation to assist breathing through an endotracheal tube or a tracheotomy; hemofiltration equipment for acute renal failure; monitoring equipment; intravenous lines for drug infusions fluids or total parenteral nutrition, nasogastric tubes, suction pumps, drains and catheters; and a wide array of drugs including inotropes, sedatives, broad spectrum antibiotics and analgesics.
[edit] Physicians, Veterinary Criticalists and Intensivists
Physicians that practice in an intensive care unit historically have been the same physicians that care for the patient before transferring to the ICU. This is still commonly the case. In some hospitals there is a special group of physicians that staff the ICU, known as Intensivists, which is becoming a speciality. Whether the intensivist becomes the lead doctor or a consultant on a case is a matter of policy in each hospital. The speciality is unusual among the specialties of medicine in that their backgrounds may be Pulmonary, Anesthesiology, Internal Medicine, or other specialties. The reason for the high representation of Pulmonary and Anesthesiology is the need to be familiar with ventilator management, although ventilating generally healthy individuals in the case of surgery is entirely different from ventilating in case of respiratory insufficiency.
In veterinary medicine, critical care medicine is recognized as a specialty and is closely allied with emergency medicine. Board-certified veterinary critical care specialists are known as criticalists, and generally are employed in referral institutions or universities.
Patient management in intensive care differs significantly between countries. In Australia, where Intensive Care Medicine is a well established speciality, ICUs are described as 'closed.'In a closed unit the intensive care specialist takes on the senior role where the patient's primary doctor now acts as a consultant. Other countries have open Intensive Care Units, where the primary doctor chooses to admit and generally makes the management decisions. There is increasingly strong evidence that 'closed' Intensive Care Units staffed by Intensivists provide better outcomes for patients. [2] [3]
[edit] References
- The ICU Book by Marino
- Procedures and Techniques in Intensive Care Medicine by Irwin and Rippe
- Halpern NA, Pastores SM, Greenstein RJ. Critical care medicine in the United States 1985-2000: an analysis of bed numbers, use, and costs. Crit Care Med 2004;32:1254-9. PMID 15187502.
[edit] See also
- Neonatal intensive care
- Intensive Care Unit
[edit] External links
- Critical Care On-Line Journal Club (via JournalReview.org)
- Veterinary Emergency And Critical Care Society
- Society of Critical Care Medicine
[edit] Notes
- ^ Kahn JM, Goss CH, Heagerty PJ, Kramer AA, O'Brien CR, Rubenfeld GD. (2006). "Hospital volume and the outcomes of mechanical ventilation.". New England Journal of Medicine 355 (1): 41-50. Retrieved on 2006-08-02.
- ^ Manthous CA, Amoateng-Adjepong Y, al-Kharrat T, Jacob B, Alnuaimat HM, Chatila W, Hall JB. (1997). "Effects of a medical intensivist on patient care in a community teaching hospital." (Abstract). Mayo Clinic Proceedings 72 (5): 391-9. Retrieved on 2006-09-02.
- ^ Hanson CW 3rd, Deutschman CS, Anderson HL 3rd, Reilly PM, Behringer EC, Schwab CW, Price J. (1999). "Effects of an organized critical care service on outcomes and resource utilization: a cohort study." (Abstract). Critical Care Medicine 27 (2): 270-4. Retrieved on 2006-09-02.
