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Calls to adult intensive care
CHAPTER 10
Calls to adult intensive care
Rachel Devlin
The purpose of this chapter is to highlight different terminology, equipment and specific issues pertinent to the intensive care patient. This chapter will cover: ● Considerations in the assessment of the ICU patient ● The environment ● Common pathologies ● Physiotherapy management. Calls to an intensive care unit (ICU) can be nerve-wracking due to the complexity of the environment, the variety of pathologies encountered and the severity of the patient’s condition. However, remember that this is a safe environment for you as all ICU patients are closely monitored. There is a higher proportion of nursing staff to patients, and staff are highly skilled and can offer a wealth of advice and assistance in an on call situation, e.g. explaining unfamiliar terminology. It is important to remember that critically ill patients may be anywhere in the hospital. As such, critical care should be viewed as a concept, rather than a location. You may be the first person to locate such a patient and in that case you should not be afraid to call for help. Many units have recognized this and have developed ‘critical care outreach teams’ to support staff. You should check your local policies to see if your unit has an outreach team and how to access them.
SPECIAL CONSIDERATIONS FOR ASSESSING ICU PATIENTS
Remember! The basic components of respiratory assessment remain the same regardless of whether the patient is on ICU or on a ward. See Chapter 2. Using a logical format allows you to identify whether the patient has (or is at risk of developing) loss of lung volume, sputum retention or increased work of breathing leading to respiratory failure (see also Chapters 6–9).
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GENERAL ● What is the patient’s global stability and response to handling? ● What has happened since admission/last treatment (e.g. intubation, lines inserted) ● What physiological parameters are the medical team working towards? ● Note the equipment attached to the patient, e.g. drips and drains. ● Are there any limitations to movement or positioning (e.g. due to attachments, equipment or spinal stability – see Chapter 14).
CVS ● What is the patient’s heart rate/rhythm? Is it compromising their blood pressure? What effect is your treatment likely to have on this? ● Is BP stable? Are they on any inotropic support?
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CNS ● Is the patient sedated? Are they on any paralysing agents? ● What is the patient’s level of consciousness? (sedation scoring, AVPU, GCS) ● Is analgesia sufficient for full assessment and treatment? ● Is there any neurological deficit evident? If so, is swallow/cough reflex affected? (see Chapter 14).
BIOCHEMISTRY ● What is Hb? ● Is clotting deranged? (look at platelets/INR/PT/APTT) ● Are there signs of infection/sepsis? (WCC/CRP/lactate)
RENAL ● What is current urine output? Overall fluid balance? ● Is the patient on any renal support? (diuretics, haemofiltration)
RS ● ● ● ●
Mode of ventilation and method of delivery? Ventilator settings? Level of oxygen? Saturations? Does the patient have a cough? Sputum on suction? Colour, volume and consistency? Clearing easily with suction? ● Are there chest drains in situ? What are they there for?
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A few additional factors need to be considered before you continue: ● Anxiety ● Explain all interventions to the patient regardless of their sedation level in order to minimize anxiety – there is good evidence that patients can hear what is happening. ● Relatives ● Friends and relatives will find this environment very stressful. This can manifest itself in many ways. Always remain calm and professional, listen to what they have to say – they can be an advocate for you with the patient. But remember you are there to treat the patient and do what you and the team feel is most appropriate for their care. ● Make sure you know who you are talking to and respect your patient’s confidentiality. ● Discuss your role with the patient’s relatives, but try to avoid having conversations about medical plans, prognosis, etc. This is the role of ICU staff. ● Expectations ● Patients in ICU are by definition critically ill; therefore there may be a high probability of death. Try to be realistic in your expectations of yourself. ● Balance the probable benefit of your treatment against the discomfort, time and energy that it may require of the patient. ● On occasion, when a patient has been weaned from support and extubated, the decision is made that the treatment will not be escalated should their condition deteriorate. In a small number of cases where the patient will not survive their illness, the ET tube may be removed and the patient made comfortable as part of the palliative process. ● The unfamiliar ● When encountering unfamiliar pathologies with an uncertain prognosis, it is important not to pre-judge the outcome of their ICU stay. Ask the nursing staff what to expect of the underlying pathology and consider any potential contraindications for physiotherapy treatment. During your induction to on call you should familiarize yourself with the equipment commonly used within ICU. Before approaching the patient, note the equipment, lines, etc. that are attached to the patient and the precautions/care you should take.
Remember! If you are unsure of any equipment or lines ask for help/explanation from ICU staff.
10
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THE ENVIRONMENT ICU has many pieces of equipment – Table 10.1 gives a brief summary of some of the common items you will see. With lots of equipment come lots of different alarm systems. For equipment such as infusion pumps it is vital you do not switch them off. However, it is helpful to nursing staff if you can identify the cause of the alarm. For monitoring and ventilators Table 10.2 highlights some of the common causes of alarms in ICU and how you should manage them. Do not switch off alarms unless you are competent to identify the cause and manage appropriately. If in doubt, ask!
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Table 10.1 ICU equipment Equipment
Explanation
Arterial line – blood pressure monitoring
● Inserted via radial, brachial or dorsalis pedis arteries ● Care with positioning to avoid disconnection or kinking of lines (may make the trace unreliable) ● Liaise with nursing staff regarding reliability of the trace ● Blood pressure cuffs may also be used
ECG electrodes – heart rate and rhythm monitoring
● Take care with techniques that may disrupt the trace and set off the alarms, e.g. manual techniques ● Always remember to check the ‘stickies’ if the trace changes
CVP (central venous pressure) line – monitors pressure in the right side of the heart
● Commonly inserted in the internal jugular or subclavian vein ● Drugs may be administered via the CVP line; if so the measurement will be inaccurate. Take care not to kink the line during turning as drug delivery may be affected ● Risk of pneumothorax during insertion; therefore ensure that patient has a CXR prior to using positive pressure adjuncts, e.g. IPPB, MHI
Invasive cardiac monitoring/ equipment (e.g. PA catheter, PiCCO/LiDCO, intra-aortic balloon pump (IABP), pacing wires)
● Refer to Chapter 15 ● Check with staff on stability of patient and limitations to movement/positioning ● There are similar risks with the insertion of PA catheters as with CVP lines
Invasive neurological monitoring/ equipment (e.g. ICP bolt, extraventricular drains (EVD) or cerebral function monitors (CFM))
● Refer to Chapter 14 ● Check with staff on stability and limitations to positioning
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Equipment
Explanation
Haemofiltration (HF) – renal failure. May also be documented as CVVHF or CVVHD
● Vas-Cath (a large-bore double-lumen cannula) inserted into the subclavian or internal jugular vein (for neck), or femoral veins (for groin) ● Take care not to kink lines – will affect function of machine. Do not flex the hip greater than 30–45º if femoral line ● Check with staff on stability and other limitations to positioning ● There will be changes in overall fluid status with patients on renal support that may predispose them to cardiovascular instability
Airways Endotracheal tube (may be oral or nasal), trachesotomy tube
● Endotracheal tube used initially ● Nasal ETT may suggest a difficult intubation – so take care ● Tracheostomy may be used to wean from mechanical ventilation. See tracheostomy section in Chapter 13 ● Ventilated patients will have a cuffed airway in place. If a patient is able to vocalize or there are audible oral noises, inform the nursing staff as there may be a cuff leak which may affect ventilation
Ventilators ● Different manufacturers of ventilator have different Be aware of the different types of names for the modes of ventilation (e.g. BiPAP, ventilator in use in your hospital. PRVC, ASB, etc.). Often the full name will give you It is of note that a variety of a clue as to the type of ventilation this is ventilatory parameters can be ● Controlled modes of ventilation – the patient changed in order to optimize gas makes little or no respiratory effort. This may exchange and minimize the indicate a more acute or severe condition, e.g. potential damage to the lungs head injury or sepsis ● Supported modes of ventilation allow the patient to trigger the ventilator, namely that they are able to initiate some breaths. This indicates that the patient’s condition is improving or less severe. These modes can be used while weaning ventilation (decreasing respiratory support) ● Modern machines will allow a patient to breathe on top of a controlled mode of ventilation. To see if a patient is doing this, look at the set breathing rate and then the actual breathing rate on the ventilator Non-invasive ventilation/CPAP
● See Chapter 9
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Table 10.1 Continued
● ● ● ●
● Analgesia, reassurance, sedation or increased ventilatory support ● Nebulized bronchodilators
● Suction or further physiotherapy intervention ● Patient may require increased FiO2
● Needs review of ventilator settings
● Bronchospasm ● Patient waking/biting on tube ● Patient waking up and making increased respiratory effort ● Increased respiratory rate, e.g. due to pain, anxiety or fatigue
● Sputum plug ● Patient waking up/coughing
● Could be any combination of the above
Increased work of breathing May alarm as: ● Decreased tidal volume ● Decreased minute volume ● Increased respiratory rate
Sputum retention May alarm as: ● Increased peak airway pressure ● Decreased SpO2 ● Decreased tidal volume
Respiratory failure
Check connections in circuit Consider repositioning Suction or further physiotherapy intervention Patient may require increased FiO2
Physiotherapy management
● ● ● ● ● Leak in circuit Dislodged ETT Excess water in circuit Sputum plug Acute lung injury
Potential causes
Problem
Reduced lung volumes May alarm as: ● Decreased tidal volume ● Decreased minute volume ● Decreased SpO2 ● Increased peak airway pressure
Table 10.2 Common causes of alarms in an ICU and their management
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● Investigation and treatment of underlying cause ● Patient requires medical review
● Infection ● Decreased blood volume, e.g. bleeding, haemofiltration ● Pain ● Anxiety
Increased heart rate
● Analgesia ● Sedation or reassurance
● Analgesia ● Sedation or reassurance
● If unreliable, use blood pressure cuff ● Ensure lines are patent for effective delivery of drugs, e.g. inotropes ● Patient may require intravenous fluids/surgical opinion ● Observe if BP returns to normal. If not, return patient to supine. If low BP persists, patient may require intravenous fluids or inotropes ● Stop technique and allow patient to settle; BP should recover quickly. If not, discuss further intervention with nursing staff. One treatment at a time may be possible or there may be a medical solution to support BP during treatment ● Administer intravenous fluids or decrease sedation if appropriate
● Pain ● Anxiety
● Due to increase/bolus of sedation
● During physiotherapy intervention, e.g. MHI or manual techniques
● Due to bleeding ● Following nursing intervention, e.g. turning
● Unreliable arterial line trace ● Kinked lines
Increased blood pressure
Decreased blood pressure
Monitor alarming
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● Patient may require anti-arrhythmic drugs, e.g. amiodarone, or cardioversion to restore sinus rhythm ● Treatment of underlying cause ● Check reliability of trace (i.e. HR from pulse oximeter and ECG trace should match). If poor, relocate probe, e.g. to toes, earlobes ● Suction or further physiotherapy intervention ● Consider repositioning or further physiotherapy intervention ● Diuretics, inotropes, renal support ● Patient may require increased FiO2
● Hypoxia ● Sepsis
● Unreliable trace
Arrhythmias, e.g. atrial fibrillation (ensure nursing staff are aware of any change in ECG trace)
Decreased SpO2
● Fluid overload
● Sputum retention ● Decreased lung volume or V/Q mismatch
● Patient may require medical review ● Monitor response to further interventions and discuss with medical team
Physiotherapy management
Potential causes
● Due to medication, e.g. beta-blockers, sedatives ● Due to vagal stimulation, e.g. following suction or movement of ETT
Problem
Decreased heart rate
Table 10.2 Continued
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COMMON PATHOLOGIES/CONDITIONS IN ICU Table 10.3 summarizes some of the common pathologies and conditions seen within the ICU. As part of your assessment you will also note that the patient may be receiving a number of drugs with which you are unfamiliar. Common drugs encountered in intensive care are described in Appendix 4. Bringing together all the information that you have gathered from your assessment will help you to identify the patient’s individual problem and allow you to develop a treatment plan (Table 10.4).
ARDS (acute respiratory distress syndrome)/ALI (acute lung injury)
● Syndrome characterized by reduction in lung compliance and need for high PEEP and oxygen requirements but as it is an interstitial pathology secretions are not generally a problem ● Caution with hands-on techniques as you do not want to de-recruit lung units (i.e. lose the splinting effect of the ventilator PEEP) ● Treatment may consist of positioning only, e.g. prone-lying to optimize gaseous exchange ● If secretions become a problem ensure adequate humidification along with other techniques to improve sputum clearance
Sepsis – systemic ● Normal WBC = 4–11 × 109/L; ↑WBC indicates infection inflammatory response ● CVS instability, e.g. decreased BP, will occur and patient syndrome (SIRS) may require cardiac support drugs or fluid management to maintain adequate perfusion ● Positioning or MHI may be contraindicated as these may compromise BP ● Urine output may decrease leading to fluid overload and pulmonary oedema. This will compromise oxygenation and the patient may require high FiO2 and increased PEEP ● If there are signs of pulmonary infection, try one treatment at a time, e.g. side-lying, and monitor the patient’s CVS response Unilateral lung pathology, e.g. pneumonia
● Self-ventilating patient – See Chapter 12 ● Intubated patients – Remember V/Q. IPPV changes the dynamics of ventilation and air is forced into area of least resistance. Therefore the airways which are open more tend to get overstretched. In a side-lying patient the nondependent area (upper lung) receives greater ventilation. Perfusion is unchanged in the ventilated patient
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Table 10.3 Common ICU pathologies and conditions
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Table 10.3 Continued
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● If the affected lung is dependent, desaturation may occur due to poor perfusion. If it is non-dependent, desaturation may occur because the disease process limits gas exchange secondary to secretions. You need to assess each patient on an individual basis and establish appropriate positions for treatment, which may be different to the position you leave the patient in Head injuries, neurosurgery and spinal cord injuries
● Refer to local hospital guidance on management ● See Chapter 14
Spinal fractures/ orthopaedic trauma
● See Chapters 13 and 14 ● Long bone fractures may cause fat emboli leading to type I respiratory failure ● Log rolling only until a full set of spinal films has been performed and the spine cleared; medical staff must document if patient can be positioned in any position other than supine ● Note orthopaedic instruction for peripheral fractures
Rib fractures/flail segment/sternal fractures/lung contusions
● Be aware of fracture sites ● For management see Chapter 15
Burns
● Ensure that the patient has effective pain relief and adequate humidification as secretions may be thick and difficult to clear ● Early, regular chest clearance is vital to remove soot (etc.) particles from the lungs. Soot around the nose and mouth is suggestive of inhalation injury which results in oedema and sputum ● Patients with large-scale burns will require rapid fluid replacement and so are prone to pulmonary oedema ● If stridor occurs, seek urgent medical advice due to risk of airway obstruction ● Postural drainage is contraindicated in the presence of head/neck oedema ● Check local policies with regard to movement and manual techniques over skin grafts. Some units allow this once the graft is established provided that the graft is healthy and there is thick padding over the affected area. Check with the on call team covering the specialty which undertook the surgery
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Table 10.3 Continued
Clotting disorders
● If INR >1.0 (associated with anticoagulants or liver dysfunction) or in the presence of DIC (disseminated intravascular coagulation), bleeding may occur leading to cardiovascular instability ● Secretions may be blood stained and care should be taken if performing suction to minimize trauma. Manual techniques may be contraindicated ● If INR <1.0 there will be a predisposition to clotting, e.g. DVT, PE ● A falling platelet count may be a sign of sepsis. Low platelets predispose to bleeding and therefore care should be taken during all interventions to minimize trauma to the patient, e.g. when repositioning the patient
Postoperative patients
● Effective pain relief is essential to ensure patient compliance with treatment ● Important to observe surgical instructions regarding positive pressure adjuncts, positioning and mobilization ● See Chapter 13
Respiratory medical patients
● See Chapter 12 ● Aim to prevent patient fatigue by management of increased work of breathing and sputum retention ● NIV may be considered. Setting up NIV may not be the role of the on call physiotherapist, so it is important to be aware of hospital policy
Renal failure patients
● See Chapter 12 ● A patient may present with respiratory problems, e.g. increased RR, but blood gas analysis shows that it is a compensatory mechanism for a primary metabolic problem, e.g. acute renal failure ● Patient may be admitted for haemofiltration; see Chapter 12 ● Main problem is commonly pulmonary oedema leading to type I respiratory failure. This may respond to diuretics and CPAP
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● Escharotomy of the chest wall; effective chest care is essential – however, analgesia is vital ● Burns patients are immunosuppressed, so it is vital to adhere to infection control policies ● Many units require that passive movements to affected areas are continued for burns patients at weekends – check local policy
As described previously
Sputum clearance techniques, positions to decrease breathlessness, reassurance
Treatment of underlying cause. Non-invasive ventilation, intubation and ventilation, increasing respiratory support. Sedation, e.g. propofol
Analgesia. Intercostal chest drain if symptomatic. See Chapter 18
Fatigue
Encourage mobilization
Spontaneous, e.g. Marfan syndrome Traumatic, e.g. stabbing
Anticoagulation, TED stockings
Inotropic support, e.g. epinephrine; diuretics, e.g. furosemide. Fluid restriction. Haemofiltration
Pneumothorax
Physiotherapy is NOT indicated for pulmonary oedema
Reintubation, bronchoscopy. Rehydration
Physiotherapy is NOT indicated for a Diuretics, intercostal chest drain. pleural effusion, although patient See Chapter 18 may respond to positions to relieve breathlessness if symptomatic
Cardiac or renal failure
Pulmonary oedema
Sputum clearance techniques. Mobilization, e.g. sitting out
Bronchodilators, diuretics, haemofiltration
Cardiac/renal failure. Fluid overload. Malignancy
Sputum plug, migration of ET tube, position in bed
Lobar collapse
Sputum clearance techniques. Positions to relieve breathlessness, reassurance
Decrease sedation, ensure adequate analgesia, increase respiratory support, e.g ↑pressure support
Further management
Pleural effusion
Previous respiratory disease, sputum retention, fluid overload, renal failure, anxiety
Bronchospasm
Sputum clearance techniques
Physiotherapy management
Physiotherapy is NOT indicated for a PE. Do NOT mobilize patient without discussing with doctors
Poor cough, pain, dehydration, fatigue
Sputum retention
Pulmonary embolus (PE)
Cause
Problem
Table 10.4 Management of ICU problems
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Key messages ● Approach assessment of the ICU patient in the same systematic and logical format that you would use to assess a ward patient. ● Work closely with the nursing and medical staff. ● Communicate the outcome of your assessment and treatment succinctly. ● Don’t be afraid to ask questions. ● Don’t be scared!
Acknowledgements The author would like to acknowledge the input of Sara Smailes in the burns section of this chapter.
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Further reading Bersten A, Soni N, Oh TE (eds) (2003) Oh’s intensive care manual, 5th edn. Oxford: Butterworth Heinemann. Hough A (2001) Physiotherapy in respiratory care: a problem solving approach to respiratory and cardiac management, 3rd edn. Cheltenham: Stanley Thornes. Pryor JA, Prasad SA (eds) (2002) Physiotherapy for respiratory and cardiac problems, 3rd edn. London: Churchill Livingstone. Singer M, Webb A (eds) (2005) Oxford handbook of critical care, 2nd revised edn. Oxford: Oxford University Press.
Calls to adult intensive care
Rachel Devlin
The purpose of this chapter is to highlight different terminology, equipment and specific issues pertinent to the intensive care patient. This chapter will cover: ● Considerations in the assessment of the ICU patient ● The environment ● Common pathologies ● Physiotherapy management. Calls to an intensive care unit (ICU) can be nerve-wracking due to the complexity of the environment, the variety of pathologies encountered and the severity of the patient’s condition. However, remember that this is a safe environment for you as all ICU patients are closely monitored. There is a higher proportion of nursing staff to patients, and staff are highly skilled and can offer a wealth of advice and assistance in an on call situation, e.g. explaining unfamiliar terminology. It is important to remember that critically ill patients may be anywhere in the hospital. As such, critical care should be viewed as a concept, rather than a location. You may be the first person to locate such a patient and in that case you should not be afraid to call for help. Many units have recognized this and have developed ‘critical care outreach teams’ to support staff. You should check your local policies to see if your unit has an outreach team and how to access them.
SPECIAL CONSIDERATIONS FOR ASSESSING ICU PATIENTS
Remember! The basic components of respiratory assessment remain the same regardless of whether the patient is on ICU or on a ward. See Chapter 2. Using a logical format allows you to identify whether the patient has (or is at risk of developing) loss of lung volume, sputum retention or increased work of breathing leading to respiratory failure (see also Chapters 6–9).
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GENERAL ● What is the patient’s global stability and response to handling? ● What has happened since admission/last treatment (e.g. intubation, lines inserted) ● What physiological parameters are the medical team working towards? ● Note the equipment attached to the patient, e.g. drips and drains. ● Are there any limitations to movement or positioning (e.g. due to attachments, equipment or spinal stability – see Chapter 14).
CVS ● What is the patient’s heart rate/rhythm? Is it compromising their blood pressure? What effect is your treatment likely to have on this? ● Is BP stable? Are they on any inotropic support?
10
CNS ● Is the patient sedated? Are they on any paralysing agents? ● What is the patient’s level of consciousness? (sedation scoring, AVPU, GCS) ● Is analgesia sufficient for full assessment and treatment? ● Is there any neurological deficit evident? If so, is swallow/cough reflex affected? (see Chapter 14).
BIOCHEMISTRY ● What is Hb? ● Is clotting deranged? (look at platelets/INR/PT/APTT) ● Are there signs of infection/sepsis? (WCC/CRP/lactate)
RENAL ● What is current urine output? Overall fluid balance? ● Is the patient on any renal support? (diuretics, haemofiltration)
RS ● ● ● ●
Mode of ventilation and method of delivery? Ventilator settings? Level of oxygen? Saturations? Does the patient have a cough? Sputum on suction? Colour, volume and consistency? Clearing easily with suction? ● Are there chest drains in situ? What are they there for?
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A few additional factors need to be considered before you continue: ● Anxiety ● Explain all interventions to the patient regardless of their sedation level in order to minimize anxiety – there is good evidence that patients can hear what is happening. ● Relatives ● Friends and relatives will find this environment very stressful. This can manifest itself in many ways. Always remain calm and professional, listen to what they have to say – they can be an advocate for you with the patient. But remember you are there to treat the patient and do what you and the team feel is most appropriate for their care. ● Make sure you know who you are talking to and respect your patient’s confidentiality. ● Discuss your role with the patient’s relatives, but try to avoid having conversations about medical plans, prognosis, etc. This is the role of ICU staff. ● Expectations ● Patients in ICU are by definition critically ill; therefore there may be a high probability of death. Try to be realistic in your expectations of yourself. ● Balance the probable benefit of your treatment against the discomfort, time and energy that it may require of the patient. ● On occasion, when a patient has been weaned from support and extubated, the decision is made that the treatment will not be escalated should their condition deteriorate. In a small number of cases where the patient will not survive their illness, the ET tube may be removed and the patient made comfortable as part of the palliative process. ● The unfamiliar ● When encountering unfamiliar pathologies with an uncertain prognosis, it is important not to pre-judge the outcome of their ICU stay. Ask the nursing staff what to expect of the underlying pathology and consider any potential contraindications for physiotherapy treatment. During your induction to on call you should familiarize yourself with the equipment commonly used within ICU. Before approaching the patient, note the equipment, lines, etc. that are attached to the patient and the precautions/care you should take.
Remember! If you are unsure of any equipment or lines ask for help/explanation from ICU staff.
10
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126
Calls to adult intensive care
THE ENVIRONMENT ICU has many pieces of equipment – Table 10.1 gives a brief summary of some of the common items you will see. With lots of equipment come lots of different alarm systems. For equipment such as infusion pumps it is vital you do not switch them off. However, it is helpful to nursing staff if you can identify the cause of the alarm. For monitoring and ventilators Table 10.2 highlights some of the common causes of alarms in ICU and how you should manage them. Do not switch off alarms unless you are competent to identify the cause and manage appropriately. If in doubt, ask!
10
Table 10.1 ICU equipment Equipment
Explanation
Arterial line – blood pressure monitoring
● Inserted via radial, brachial or dorsalis pedis arteries ● Care with positioning to avoid disconnection or kinking of lines (may make the trace unreliable) ● Liaise with nursing staff regarding reliability of the trace ● Blood pressure cuffs may also be used
ECG electrodes – heart rate and rhythm monitoring
● Take care with techniques that may disrupt the trace and set off the alarms, e.g. manual techniques ● Always remember to check the ‘stickies’ if the trace changes
CVP (central venous pressure) line – monitors pressure in the right side of the heart
● Commonly inserted in the internal jugular or subclavian vein ● Drugs may be administered via the CVP line; if so the measurement will be inaccurate. Take care not to kink the line during turning as drug delivery may be affected ● Risk of pneumothorax during insertion; therefore ensure that patient has a CXR prior to using positive pressure adjuncts, e.g. IPPB, MHI
Invasive cardiac monitoring/ equipment (e.g. PA catheter, PiCCO/LiDCO, intra-aortic balloon pump (IABP), pacing wires)
● Refer to Chapter 15 ● Check with staff on stability of patient and limitations to movement/positioning ● There are similar risks with the insertion of PA catheters as with CVP lines
Invasive neurological monitoring/ equipment (e.g. ICP bolt, extraventricular drains (EVD) or cerebral function monitors (CFM))
● Refer to Chapter 14 ● Check with staff on stability and limitations to positioning
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Equipment
Explanation
Haemofiltration (HF) – renal failure. May also be documented as CVVHF or CVVHD
● Vas-Cath (a large-bore double-lumen cannula) inserted into the subclavian or internal jugular vein (for neck), or femoral veins (for groin) ● Take care not to kink lines – will affect function of machine. Do not flex the hip greater than 30–45º if femoral line ● Check with staff on stability and other limitations to positioning ● There will be changes in overall fluid status with patients on renal support that may predispose them to cardiovascular instability
Airways Endotracheal tube (may be oral or nasal), trachesotomy tube
● Endotracheal tube used initially ● Nasal ETT may suggest a difficult intubation – so take care ● Tracheostomy may be used to wean from mechanical ventilation. See tracheostomy section in Chapter 13 ● Ventilated patients will have a cuffed airway in place. If a patient is able to vocalize or there are audible oral noises, inform the nursing staff as there may be a cuff leak which may affect ventilation
Ventilators ● Different manufacturers of ventilator have different Be aware of the different types of names for the modes of ventilation (e.g. BiPAP, ventilator in use in your hospital. PRVC, ASB, etc.). Often the full name will give you It is of note that a variety of a clue as to the type of ventilation this is ventilatory parameters can be ● Controlled modes of ventilation – the patient changed in order to optimize gas makes little or no respiratory effort. This may exchange and minimize the indicate a more acute or severe condition, e.g. potential damage to the lungs head injury or sepsis ● Supported modes of ventilation allow the patient to trigger the ventilator, namely that they are able to initiate some breaths. This indicates that the patient’s condition is improving or less severe. These modes can be used while weaning ventilation (decreasing respiratory support) ● Modern machines will allow a patient to breathe on top of a controlled mode of ventilation. To see if a patient is doing this, look at the set breathing rate and then the actual breathing rate on the ventilator Non-invasive ventilation/CPAP
● See Chapter 9
10
Table 10.1 Continued
● ● ● ●
● Analgesia, reassurance, sedation or increased ventilatory support ● Nebulized bronchodilators
● Suction or further physiotherapy intervention ● Patient may require increased FiO2
● Needs review of ventilator settings
● Bronchospasm ● Patient waking/biting on tube ● Patient waking up and making increased respiratory effort ● Increased respiratory rate, e.g. due to pain, anxiety or fatigue
● Sputum plug ● Patient waking up/coughing
● Could be any combination of the above
Increased work of breathing May alarm as: ● Decreased tidal volume ● Decreased minute volume ● Increased respiratory rate
Sputum retention May alarm as: ● Increased peak airway pressure ● Decreased SpO2 ● Decreased tidal volume
Respiratory failure
Check connections in circuit Consider repositioning Suction or further physiotherapy intervention Patient may require increased FiO2
Physiotherapy management
● ● ● ● ● Leak in circuit Dislodged ETT Excess water in circuit Sputum plug Acute lung injury
Potential causes
Problem
Reduced lung volumes May alarm as: ● Decreased tidal volume ● Decreased minute volume ● Decreased SpO2 ● Increased peak airway pressure
Table 10.2 Common causes of alarms in an ICU and their management
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● Investigation and treatment of underlying cause ● Patient requires medical review
● Infection ● Decreased blood volume, e.g. bleeding, haemofiltration ● Pain ● Anxiety
Increased heart rate
● Analgesia ● Sedation or reassurance
● Analgesia ● Sedation or reassurance
● If unreliable, use blood pressure cuff ● Ensure lines are patent for effective delivery of drugs, e.g. inotropes ● Patient may require intravenous fluids/surgical opinion ● Observe if BP returns to normal. If not, return patient to supine. If low BP persists, patient may require intravenous fluids or inotropes ● Stop technique and allow patient to settle; BP should recover quickly. If not, discuss further intervention with nursing staff. One treatment at a time may be possible or there may be a medical solution to support BP during treatment ● Administer intravenous fluids or decrease sedation if appropriate
● Pain ● Anxiety
● Due to increase/bolus of sedation
● During physiotherapy intervention, e.g. MHI or manual techniques
● Due to bleeding ● Following nursing intervention, e.g. turning
● Unreliable arterial line trace ● Kinked lines
Increased blood pressure
Decreased blood pressure
Monitor alarming
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● Patient may require anti-arrhythmic drugs, e.g. amiodarone, or cardioversion to restore sinus rhythm ● Treatment of underlying cause ● Check reliability of trace (i.e. HR from pulse oximeter and ECG trace should match). If poor, relocate probe, e.g. to toes, earlobes ● Suction or further physiotherapy intervention ● Consider repositioning or further physiotherapy intervention ● Diuretics, inotropes, renal support ● Patient may require increased FiO2
● Hypoxia ● Sepsis
● Unreliable trace
Arrhythmias, e.g. atrial fibrillation (ensure nursing staff are aware of any change in ECG trace)
Decreased SpO2
● Fluid overload
● Sputum retention ● Decreased lung volume or V/Q mismatch
● Patient may require medical review ● Monitor response to further interventions and discuss with medical team
Physiotherapy management
Potential causes
● Due to medication, e.g. beta-blockers, sedatives ● Due to vagal stimulation, e.g. following suction or movement of ETT
Problem
Decreased heart rate
Table 10.2 Continued
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COMMON PATHOLOGIES/CONDITIONS IN ICU Table 10.3 summarizes some of the common pathologies and conditions seen within the ICU. As part of your assessment you will also note that the patient may be receiving a number of drugs with which you are unfamiliar. Common drugs encountered in intensive care are described in Appendix 4. Bringing together all the information that you have gathered from your assessment will help you to identify the patient’s individual problem and allow you to develop a treatment plan (Table 10.4).
ARDS (acute respiratory distress syndrome)/ALI (acute lung injury)
● Syndrome characterized by reduction in lung compliance and need for high PEEP and oxygen requirements but as it is an interstitial pathology secretions are not generally a problem ● Caution with hands-on techniques as you do not want to de-recruit lung units (i.e. lose the splinting effect of the ventilator PEEP) ● Treatment may consist of positioning only, e.g. prone-lying to optimize gaseous exchange ● If secretions become a problem ensure adequate humidification along with other techniques to improve sputum clearance
Sepsis – systemic ● Normal WBC = 4–11 × 109/L; ↑WBC indicates infection inflammatory response ● CVS instability, e.g. decreased BP, will occur and patient syndrome (SIRS) may require cardiac support drugs or fluid management to maintain adequate perfusion ● Positioning or MHI may be contraindicated as these may compromise BP ● Urine output may decrease leading to fluid overload and pulmonary oedema. This will compromise oxygenation and the patient may require high FiO2 and increased PEEP ● If there are signs of pulmonary infection, try one treatment at a time, e.g. side-lying, and monitor the patient’s CVS response Unilateral lung pathology, e.g. pneumonia
● Self-ventilating patient – See Chapter 12 ● Intubated patients – Remember V/Q. IPPV changes the dynamics of ventilation and air is forced into area of least resistance. Therefore the airways which are open more tend to get overstretched. In a side-lying patient the nondependent area (upper lung) receives greater ventilation. Perfusion is unchanged in the ventilated patient
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Table 10.3 Common ICU pathologies and conditions
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Table 10.3 Continued
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● If the affected lung is dependent, desaturation may occur due to poor perfusion. If it is non-dependent, desaturation may occur because the disease process limits gas exchange secondary to secretions. You need to assess each patient on an individual basis and establish appropriate positions for treatment, which may be different to the position you leave the patient in Head injuries, neurosurgery and spinal cord injuries
● Refer to local hospital guidance on management ● See Chapter 14
Spinal fractures/ orthopaedic trauma
● See Chapters 13 and 14 ● Long bone fractures may cause fat emboli leading to type I respiratory failure ● Log rolling only until a full set of spinal films has been performed and the spine cleared; medical staff must document if patient can be positioned in any position other than supine ● Note orthopaedic instruction for peripheral fractures
Rib fractures/flail segment/sternal fractures/lung contusions
● Be aware of fracture sites ● For management see Chapter 15
Burns
● Ensure that the patient has effective pain relief and adequate humidification as secretions may be thick and difficult to clear ● Early, regular chest clearance is vital to remove soot (etc.) particles from the lungs. Soot around the nose and mouth is suggestive of inhalation injury which results in oedema and sputum ● Patients with large-scale burns will require rapid fluid replacement and so are prone to pulmonary oedema ● If stridor occurs, seek urgent medical advice due to risk of airway obstruction ● Postural drainage is contraindicated in the presence of head/neck oedema ● Check local policies with regard to movement and manual techniques over skin grafts. Some units allow this once the graft is established provided that the graft is healthy and there is thick padding over the affected area. Check with the on call team covering the specialty which undertook the surgery
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Table 10.3 Continued
Clotting disorders
● If INR >1.0 (associated with anticoagulants or liver dysfunction) or in the presence of DIC (disseminated intravascular coagulation), bleeding may occur leading to cardiovascular instability ● Secretions may be blood stained and care should be taken if performing suction to minimize trauma. Manual techniques may be contraindicated ● If INR <1.0 there will be a predisposition to clotting, e.g. DVT, PE ● A falling platelet count may be a sign of sepsis. Low platelets predispose to bleeding and therefore care should be taken during all interventions to minimize trauma to the patient, e.g. when repositioning the patient
Postoperative patients
● Effective pain relief is essential to ensure patient compliance with treatment ● Important to observe surgical instructions regarding positive pressure adjuncts, positioning and mobilization ● See Chapter 13
Respiratory medical patients
● See Chapter 12 ● Aim to prevent patient fatigue by management of increased work of breathing and sputum retention ● NIV may be considered. Setting up NIV may not be the role of the on call physiotherapist, so it is important to be aware of hospital policy
Renal failure patients
● See Chapter 12 ● A patient may present with respiratory problems, e.g. increased RR, but blood gas analysis shows that it is a compensatory mechanism for a primary metabolic problem, e.g. acute renal failure ● Patient may be admitted for haemofiltration; see Chapter 12 ● Main problem is commonly pulmonary oedema leading to type I respiratory failure. This may respond to diuretics and CPAP
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● Escharotomy of the chest wall; effective chest care is essential – however, analgesia is vital ● Burns patients are immunosuppressed, so it is vital to adhere to infection control policies ● Many units require that passive movements to affected areas are continued for burns patients at weekends – check local policy
As described previously
Sputum clearance techniques, positions to decrease breathlessness, reassurance
Treatment of underlying cause. Non-invasive ventilation, intubation and ventilation, increasing respiratory support. Sedation, e.g. propofol
Analgesia. Intercostal chest drain if symptomatic. See Chapter 18
Fatigue
Encourage mobilization
Spontaneous, e.g. Marfan syndrome Traumatic, e.g. stabbing
Anticoagulation, TED stockings
Inotropic support, e.g. epinephrine; diuretics, e.g. furosemide. Fluid restriction. Haemofiltration
Pneumothorax
Physiotherapy is NOT indicated for pulmonary oedema
Reintubation, bronchoscopy. Rehydration
Physiotherapy is NOT indicated for a Diuretics, intercostal chest drain. pleural effusion, although patient See Chapter 18 may respond to positions to relieve breathlessness if symptomatic
Cardiac or renal failure
Pulmonary oedema
Sputum clearance techniques. Mobilization, e.g. sitting out
Bronchodilators, diuretics, haemofiltration
Cardiac/renal failure. Fluid overload. Malignancy
Sputum plug, migration of ET tube, position in bed
Lobar collapse
Sputum clearance techniques. Positions to relieve breathlessness, reassurance
Decrease sedation, ensure adequate analgesia, increase respiratory support, e.g ↑pressure support
Further management
Pleural effusion
Previous respiratory disease, sputum retention, fluid overload, renal failure, anxiety
Bronchospasm
Sputum clearance techniques
Physiotherapy management
Physiotherapy is NOT indicated for a PE. Do NOT mobilize patient without discussing with doctors
Poor cough, pain, dehydration, fatigue
Sputum retention
Pulmonary embolus (PE)
Cause
Problem
Table 10.4 Management of ICU problems
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Key messages ● Approach assessment of the ICU patient in the same systematic and logical format that you would use to assess a ward patient. ● Work closely with the nursing and medical staff. ● Communicate the outcome of your assessment and treatment succinctly. ● Don’t be afraid to ask questions. ● Don’t be scared!
Acknowledgements The author would like to acknowledge the input of Sara Smailes in the burns section of this chapter.
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Further reading Bersten A, Soni N, Oh TE (eds) (2003) Oh’s intensive care manual, 5th edn. Oxford: Butterworth Heinemann. Hough A (2001) Physiotherapy in respiratory care: a problem solving approach to respiratory and cardiac management, 3rd edn. Cheltenham: Stanley Thornes. Pryor JA, Prasad SA (eds) (2002) Physiotherapy for respiratory and cardiac problems, 3rd edn. London: Churchill Livingstone. Singer M, Webb A (eds) (2005) Oxford handbook of critical care, 2nd revised edn. Oxford: Oxford University Press.