Centres of Excellence

There are many problems for which a person may need care in an ICU. Some of the more common problems and conditions that either bring a patient to the ICU or develop while the patient is in the unit are being explained here:

• Acute respiratory failure: Acute respiratory failure means lungs inability to remove carbon dioxide (CO2) and maintain oxygen level in the blood. There are many reasons which range from mild to severe. These are pneumonia or heart failure, chronic obstructive pulmonary disease (COPD), asthma and the most severe one like ALI / ARDS. Usually these patients need some type of mechanical support to help their breathing. Support may be provided by a tight-fitting mask that delivers oxygen under pressure or through the insertion of an endotracheal tube (breathing tube) into the trachea (windpipe). In ARDS the lungs cannot supply oxygen to the blood, and a ventilator (breathing machine) is usually needed.
• Shock: In shock the organs of the body do not get enough blood flow and oxygen to function normally. Shock can be caused by many reasons. The 4 most common causes and their treatments are: Hypovolemic Shock-severe dehydration or massive blood loss. Treatment: intravenous fluids (IV) and/or blood transfusions. Cardiogenic Shock-cardiac or heart failure. Treatment: medications or devices to improve heart function. Septic Shock-severe infection resulting in organ failure. Treatment: intravenous fluids (IV) and medications to increase blood pressure and treat the infection. If shock cannot be reversed in a matter of days the body's organs will start to shut down. This may lead to death.
• Infections: Infections are a common cause of ICU admission. It can also develop while a patient is in the ICU. In ICU, infections occur for many reasons. Usually the illness that has brought the patient to the ICU decreases the immunity and lessened the ability to fight off infections. In addition, a patient often needs devices like a breathing tube and intravenous lines. These medical devices are necessary, but are foreign to the body and can lead to infections. The most common infection in a patient on a ventilator is pneumonia or an infection of the lung. This may be mild or may acquire severe form causing sepsis and ARDS. These are treated with various combinations of antibiotics.
  Another severe infection that can occur is bacteremia or infection of the blood. This infection may be caused by the presence of intravenous lines that the patient needs to receive medications and fluids. This is called a line infection or line sepsis. In this situation, the intravenous line needs to be removed and a new line placed in a different location. Line sepsis can also lead to hypotension and ARDS. These are usually treated with antibiotics.
  Other infections that can occur include UTIs or urinary tract infections from a urinary catheter. There may be infections in the bowel that may cause diarrhea. Wound infections may occur from a recent surgery in which the surgical incision has not completely healed yet. These infections are usually treated fairly easily with antibiotics.
• Sepsis and severe sepsis: The uncontrolled inflammation in response to the infection and/or injury is called sepsis. Severe sepsis occurs when this inflammation begins to affect the function of the body (renal failure and acute respiratory failure, to name a few), and the patient becomes very sick. Aggressive antibiotics, fluids, other medications, and sometimes surgery may be used to treat sepsis and severe sepsis, while other forms of support (dialysis, ventilation) may be needed to support the body's function.
• Kidney (renal) failure: The kidneys remove water and waste products from the body. Kidney or renal failure is very common in the ICU and can be the reason the patient came to the ICU. It may also develop at any time while the patient is in the ICU.Two major problems occur with renal failure. First, the body is unable to remove extra water from the body. This results in the accumulation of the water in the skin and in the body organs. This leads to swelling of the body. Body looks puffy. Body functions of the other organs also decreases because of extra water. The second function of the kidneys is to remove toxins from the body. When those toxins start to build up they affect the brain and the patient gets sleepy and can become unresponsive (goes into a coma). These toxins are not damaging the brain and the patient should wake up again if the toxins can be removed. If the toxins build up enough, the heart may stop and the patient will die from renal failure.
  Renal failure can be mild to severe. Mild causes can be treated conservatively and sometimes with some medications. Severe renal failure usually requires the need for dialysis (a machine to take over the function of the kidneys and remove the toxins and the extra water). Dialysis does not cure the renal failure. Dialysis only allows the body to stay alive while the kidneys are improving. For dialysis, a catheter is also inserted in large blood vessel of the body.
  There are 2 major types of dialysis: intermittent or continuous. Intermittent dialysis is a treatment that uses a machine for 3 to 4 hours a day or every 1-2 day later. Continuous dialysis is a machine that runs throughout the day or even more. The sicker a patient is the more likely they will need continuous dialysis.
  Recovery of the kidneys depends on the removal of the cause. If kidney failure is acute, it usually recovers, but sometimes it does not recover at all. In patients who have pre-existing decreased renal function, their chances are much lower. Even in acute renal failure, it may take weeks or months before full recovery of the kidneys and the patients’ might need dialysis for some time.    
• Neurological disorders:There are many neurologic (brain) conditions for which patient may be in an ICU. These may include traumatic brain injuries, strokes, infections, or changes that occur when a patient is critically ill. The patient may be sleepy, disoriented, frightened, or agitated. May require calming medications and restraints to prevent harming him or herself. The patient may not be awake at all while they remain critically ill. These changes are related to how sick the patient is, and usually resolves if the overall condition improves. Elderly patients are extremely susceptible to these changes due to the unfamiliar environment and the change in sleep patterns that occur in the critical care unit.
• Stress ulcer and Thrombus: The critically ill patient can develop bleeding from the stomach, which is called as stress ulcer. These can occur even if the medications are being given to prevent this. Usually the bleeding stops by itself but often requires blood transfusions. Occasionally surgery or another procedure needs to be considered. Critically ill patients also are at risk for developing blood clots (thrombus) in their legs and lungs. Most of the patients are given medications, or devices are placed on their legs to prevent this; but, it can occur even with these measures. The blood clot can be minor and only need anticoagulation to treat or it can be life threatening.
• Multiple Organ Dysfunction Syndrome (MODS): The critical illness that brings a patient to the ICU has the potential to affect the other organs in the body which results in failure of these organs. This is called Multiple Organ Dysfunction Syndrome or MODS. The treatment for MODS is only supportive. Once patient develops MODS, their chances of survival decreases.

As a family member, you may feel helpless when your patient is in ICU. This brochure is designed to provide strategies to help you cope with visiting someone who has a prolonged critical illness.
It has been realized now that a strong influence, positive reinforcement and encouragement from close friends and family works wonder in the outcome of the patient. Because of this, your well being is important to your loved one and us. The following recommendations are designed to provide you with strategies that will help you take care of yourself during this difficult time.

• Take care of yourself
  Take proper healthy food and adequate sleep. This will enhance your ability to cope with the adverse information which you might get from the health care provider. Also this helps you in dealing with stressful situations. You are not required all the time in an ICU; a trained medical team is there to take care for your patient. The patients are closely monitored even though there is not care providers directly in the patient's room at all times.
• Gathering support
  It is very important if you can gather support from family and friends. If someone comes to visit, take that opportunity for a little time to refresh yourself. They may visit the patient rotation wise which will free you for a while.
• Identify a family spokesperson
  The role of this person will be to get the patient information form the health acre provider and pass on to all the friends and relatives who need to be reached each day. The spokesperson should remain the same throughout the patient stay. This prevents multiple time repetition of the patient information being given by the medical team and also save their time. Secondly, correct information is passed rather than multiple meaning of same information being distributed if there are multiple spokesperson.
• Support at home
  As you spend many hours in the intensive care unit it is important someone take care of your children, house maintenance and pending bills if required.
• Prepare yourself daily
  Prepare yourself for any setbacks. Most patients in the ICU are borderline. Some days are good and some are bad. Concentrate on the steps taken forward and view the steps backward as hurdles that can be overcome. Try not to get discouraged. Like the patient, it is also normal for family and friends to have both good and bad days.
• Purchase a notebook
  Please write the name of the intensivist, the physicians, the social worker, and any other care provider that is involved with the care of your patient. Also write the list of person you need to contact everyday or other. You can also write the list of questions you need to discuss with the medical team and can keep the daily record of the events-good or bad occurring to your patient.
• Be positive!
  Keep your faith and your hope strong, making sure that everybody is encouraging and hopeful while with your loved one. Always try to talk to your patient even if he is not alert by introducing yourself and talking regarding current events. All these things can help with their recovery.
• Hospital resources
  A social worker or priest or counsellor can assist you while your patient is in the ICU. They can also give you grief counseling or spiritual support for your family or the patient. Do not hesitate to contact them and request various resources.

This guide will help you understand how your relative looks in the ICU.

How will my relative look?
Your patient may have multiple tubes and lines in place when they are in the ICU. There are many variations of the types of tubes and monitors. Most of these devices are temporary and may be removed when they are no longer needed. Ask the nurse if you see something that you do not understand, or that does not seem right.

• Heart Monitor Leads: to monitor the electrical activity of the heart. 
• Pulse Oximeter: A small probe attached to the finger, nose, or ear that helps monitor the oxygen level in the blood and the patient's pulse.  
• Urinary (foley) Catheter: A catheter inserted to the bladder to drain the urine into a bag. 
• IV canula: A small plastic tube placed into the vein, which is used to give fluid or medications. 
• Blood Pressure Cuff: A large cuff placed on the arm or the leg, which may be automatically or manually inflated so that the blood pressure can be evaluated.  
• Arterial Line: A small tube or catheter that is inserted into the artery to continuously monitor the blood pressure. 
• Central Line/PA Catheter: A catheter in the neck, chest, or groin that helps in monitoring and treating the flow of blood. Some of these catheters may be used for giving nutrition and other medications.  
• Intracranial Pressure Catheter and/or Ventriculostomy: A small tube or catheter inserted into the brain to monitor the brain swelling. This may also be used to drain excess fluid.
• Endotracheal Tube (ETT): A breathing tube inserted through the mouth or nose that is connected to the breathing machine (ventilator).  
• Tracheostomy Tube: A breathing tube inserted in the neck usually when ventilator (assisted) breathing is needed for a long period of time.  
• Chest Tube: A larger tube inserted in the space between chest wall and the lungs. This tube removes free air or blood that may make it difficult for the patient to breathe. 
• Nasogastric Tube: A tube inserted into the stomach or intestines to provide nutrition and remove gastric acid or secretions. 
• Dialysis Catheter: A tube-like catheter inserted in the groin or neck. The catheter is hooked up to external tubing and a dialysis machine, which cleans the blood and assists the kidneys.  
• Intra-Aortic Balloon Pump (IABP): A catheter inserted into the groin, which assists the heart with pumping blood.

• Bruising: Intensive care patients require a large number of blood tests. Even when the lab tests are drawn correctly, bruising may occur. Some illnesses make patient more prone to bruising. Bruising may occur because the illness makes it difficult for blood to clot. Patients with liver problems, infections, poor nutrition or those who are elderly bruise easily. Bruises also develop after trauma.
• Oozing: In some critical illnesses, the body may ooze straw-colored fluid out of the puncture sites from lab draws and from any break or tear in the skin. The oozing is a result of the swelling (the accumulation of fluid in the tissues). The straw-colored fluid is plasma that has been pushed or leaked into the tissues from bed rest, ventilator breathing, liver failure, heart failure, or poor nutrition.
• Skin tears: They can happen when bandages and tapes are removed from the skin. The nurse will use the gentlest tape/bandage available that will still stick to the skin. Bandages are necessary over wounds as well as to keep the intravenous lines and other tubes in place. Skin tears are unavoidable in people who have taken steroids, have a history of smoking, or have poor nutrition. The frail elderly are also at high risk of skin tearing.
• Restraints: Patients hands may be tied down if they have a tube inserted in the mouth. Usually patients tolerate the tube but sometimes it become very necessary so that they do not pull out the tube.
• Ileostomy or colostomy: An opening is made in the wall of the stomach to allow evacuation of bowel content or stool. This is referred to as the ileostomy or colostomy. These openings may be temporary or permanent, depending on the reason for the opening.

The patient may awaken and feel confused about their whereabout and what has happened to them. They may also be anxious or in pain. To reduce anxiety and pain, sedation (relaxing medicine) and pain medication (analgesia) may be needed. Sedatives relax and calm the patient, causing sleep and possibly amnesia. Analgesics significantly diminish the pain. While sedated it may be difficult for the patient to think clearly.
Sometimes the patients during treatment may behave in an unusual manner. They may seem angry, combative, hostile, or just different. It is important that you relay to the nurse and doctor the difference in the patient's personality, so a decision can be made about whether the medicine should be changed or if this change is unrelated to the medication.
The patient may behave in ways that surprise and distress you. This may be a result of fear, frustration, or actual chemical changes in the body. Usually this behavior resolve as the disease / condition improves.

There are many different reasons why a critically ill person may not speak. The reasons are as follows:

• Presence of breathing tube (passed through the vocal cords and prevents speech)
• Use of relaxing medicine (sedation) and pain relief medications (analgesia) to help them tolerate the breathing tube or overcome pain.
• Brain injury either by stroke or trauma
• Sometimes fluids, chemicals, and toxins in the blood will make a person sleepy, disoriented, hostile, combative, or even unarousable (comatose).

While any person is not talking or is in a deep sleep it is important to keep speaking to them. You can help by talking in soothing tones, telling stories, and supplying them with normal information to keep the brain active, yet calm. The voice of someone they know is helpful in most cases.