Introduction, function of ICU. Lorx András

Transcription

1 Introduction, function of ICU Lorx András

2 AOANEANE_1A Intensive Therapy and Anaesthesiology AOVANE104_1A Anaesthesiology and Intensive Therapy Compulsory Elective Credit: 2 Lectures, practices Exam: MCQ test (from the 2 nd oral possible) Credit: 2 Lectures: regular attendance is required (max. 3 absence) Exam: MCQ test

3 The place of ICU

4 Kútvölgyi Városmajor

5 Baleseti KözpontK zpont

6 AEK

7 The target To have a general insight into the everyday's of an ICU The approach of a critically ill patient, assessment, basics of therapy Equipments Anaesthesia, perioperative management

8 Your website: It is compatible with Internet Explorer

9 NEPTUN groups - lectures Max. 10 students in a group Group assignments strictly according to the NEPTUN Changes between groups just through the NEPTUN

10 Practices Version 4.0 INTENSIVE THERAPY AND ANAESTHESIOLOGY 2010/11/1 semester IX IX IX IX X.1. X X X X XI Group/Week Monday 10:40-12:10 EM-16 BEV-Kut GiVEn-Kut Card-IA-Major EM-1 BEV-Kut GiVEn-Kut Card-IA-Major Resp-Int-Kut Traum-IA-BK Ane-Kut EM-2 BEV-Kut GiVEn-Kut Card-IA-Major Resp-Int-Kut Traum-IA-BK EM-3 BEV-Kut GiVEn-Kut Card-IA-Major Resp-Int-Kut Traum-IA-BK EM-4 BEV-Kut Card-IA-Major Resp-Int-Kut Traum-IA-BK EM-5 BEV-Kut GiVEn-Kut Card-IA-Major Resp-Int-Kut EM-6 BEV-Kut GiVEn-Kut Card-IA-Major Resp-Int-Kut Traum-IA-BK EM-7 BEV-Kut GiVEn-Kut Card-IA-Major Resp-Int-Kut Traum-IA-BK EM-8 BEV-Kut Card-IA-Major Resp-Int-Kut Traum-IA-Hk EM-9 BEV-Kut GiVEn-Kut Card-IA-Major Resp-Int-Kut EM-15 BEV-Kut GiVEn-Kut HiFi-Sim-Kut Wedn e sday F riday F riday 8:30-10:00 12:30-14:00 14:15-15:4 5 EM-10 BEV-Kut GiVEn-Kut Card-IA-Major Resp-Int-Kut Traum-IA-Hk EM-11 BEV-Kut GiVEn-Kut Card-IA-Major Resp-Int-Kut Traum-IA-Hk EM-12 BEV-Kut Card-IA-Major Resp-Int-Kut Traum-IA-Hk EM-13 BEV-Kut GiVEn-Kut Card-IA-Major Resp-Int-Kut EM-14 BEV-Kut GiVEn-Kut HiFi-Sim-Kut Intensive therapy and Anaesthesiology - T y p e s o f P r a c t i c e s Intensive therapy and anaesthesiology - P l a c e s o f P r BEV-Kut Introduction - Equipments - Examination Kútvölgyi Kut SE KútvölgyiClinical Center GiVEn-Kut Pancreatitis, GIH, kidney, liver, endocrin Kútvölgyi Major SE Városmajor Clinical Center Card-IA-Major Cardiovascular intensive therapy Major BK Baleseti Központ Trauma Center 7th floor ICU Resp-Int-Kut Respiratory failure and ventilation Kútvölgyi Hk Honvédkórház - Állami Egészségügyi Központ Military Hospital Traum-IA-BK Traumatologic intensive therapy and anaesthesia Baleseti Központ Traum-IA-Hk Traumatologic intensive therapy and anaesthesia Honvédkórház Ane-Kut Anaesthesiology Kútvölgyi HiFiSim-Kut High-Fidelity Simulation Kútvölgyi

11 Practices Attendance is mandatory (max. 2 absence) Signatures collected in all practices Attendance is accepted according to the schedule and Neptun group assignment

12 Economic Impact of ICU <10% of hospital beds 30% of acute care hospital cost >20% of hospital budget 1% of GNP expended for ICU care With aging of the population Demand for critical care service will increase

13 ICU So expensive per patient per time interval We need data about the type and quality provided in ICU

14 ICU Model Care Full-time intensivist model : patient care is provided by an intensivist Consultant intensivist model : an intensivist consults for another physician to coordinate or assist in critical care, but dose not have primary responsibility for care Multiple consultant model: multiple specialists are involved in the patient care, (esp. R/T doctors for ventilators), but none is designated especially as the consultant intensivist Single physician model : primary physician provides all ICU care

15 Open Units Definition : any attending physician with hospital admitting privileges can be the physician of record and direct ICU care. (All other physicians are consultants) Disadvantage : lack of a cohesive plan Inconsistent night coverage Duplication of services

16 Closed Units Definition: An intensivist is the physician of record for ICU patients. (other physicians are consultants), All orders & procedures carried out by ICU staff advantage: improved efficiency standardized protocol for care disadvantage: potential to lock out private physician increase physician conflict

17 Transitional Units Definition: intensives are locally present shared comanaged care between ICU staff and private physician ICU staff is a final common pathway for orders and procedures Advantage: reduce physician conflict, standard policies and procedures usually present Disadvantage: confusion and conflict regarding final authority & responsibilities for patient care decision

18 Advantages of Intensivists Morbidity (ICU, 30-day, hospital) Cost Length of stay (ICU, hospital) Complication

19 Well organized A Good ICU trust coordinated care Full-time intensivist: daily round protocol & policies (eg: how to DC elective operation when bed not available) bedside nurses (master degree) no intern

20 A Good ICU A team: doctors, nurses, R/T, pharmacists led by full time intensivists critical care trained available in a timely fashion (24hr/day) no competiting clinical responsibilities during duty closed units, if resources allow

21 Role and function of ICU Roles of ICU: (MNT) Level I Level II Level III HDU ICU Intensive Monitoring Intensive Nursing Intensive Therapy

22 Intensive therapy/critical care medicine: temporary support or replacement of functionally disturbed or failing vital functions like: Respiration Circulation Metabolism Temperature & therapy of the underlying diseases at the same time

23 Main admission indications: Major surgery Acute respiratory failure Acute circulatory failure Acute renal failure Acute hepatic failure Acute metabolic/endocrine failures Shock-states Intoxications Tetanus Hemostatic failure Fluid-electrolyte, acid-base disturbances Postoperative complications Multiple trauma/polytrauma Burns Coma Eclampsia Post-resuscitation period Gastrointestinal Bleeding

24 Organisational considerations: Classification: Single-discipline ICU (surgical ICU, medical ICU, CCU, burn unit, etc.) General multidisciplinary ICU Pediatric and neonatal ICU Postoperative high dependency unit

25 Organisational aspects: 1. What type? General multidisciplinary ICU is more cost-effective than singlediscipline ICU Critically ill have the same pathophysiological processes regardless of the primary disease, and they require the same approaches to support vital organs. For example single-discipline doctors lack the experience and expertise to deal with the complexities of MODS/MOF. 2. How large? The number of ICU beds usually ranges from 1-4 / 100 total hospital beds. ICU beds < 4 is resource consuming; ICU beds > 20 hard to manage 3. Where? Possible limitation of the movement of critically ill (Op. theatre, ER, CT, etc.)

26 Level of Care and Resuscitation Measures Policy Level 1: Maximal interventions (including CPR, ICU) Level 2: Maximal interventions with some restrictions to resuscitative measures Level 3: Maximal interventions on the ward; no CPR; no transfer to an ICU. Level 4: Interventions aim to treat easily reversible conditions, maintenance of function and comfort care. No CPR, No ICU. Level 5: Interventions adapted to end of life. No CPR, No ICU, Focus on symptom relief. The form must be signed by the physician. The signature of the patient or surrogate involved in the planning of care is optional.

27

28

29