Intensive care medicine

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"high dependency unit" redirects here. For the New Zealand psychedelic rock band, see High
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Mechanical ventilation may be required if a patient's unassisted breathing is insufficient to oxygenatethe blood.
Intensive care medicine or critical care medicine is a branch of medicine concerned with
the diagnosis and management of life-threatening conditions requiring sophisticated organ
support and invasive monitoring.
Contents
[hide]
1 Overview
2 Organ systems
3 Equipment and systems
4 Medical specialties
5 History
o 5.1 Florence Nightingale era
o 5.2 Dandy era
o 5.3 Ibsen era
o 5.4 Safar era
6 See also
7 Notes
8 References
9 External links
Overview[edit]
Patients requiring intensive care may require support for instability (hypertension/hypotension),
airway or respiratory compromise (such as ventilator support), acute renal failure, potentially
lethal cardiac arrhythmias, or the cumulative effects of multiple organ failure, more commonly
referred to now as multiple organ dysfunction syndrome. They may also be admitted for
intensive/invasive monitoring, such as the crucial hours after major surgery when deemed too
unstable to transfer to a less intensively monitored unit.
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.
[citation needed]
A prime requisite for admission to
an intensive care unit (ICU) is that the underlying condition can be overcome.
[citation needed]

Medical studies suggest a relation between 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.
In general, it is the most expensive, technologically advanced and resource-intensive area of
medical care. In the United States, estimates of the 2000 expenditure for critical care medicine
ranged from US$1555 billion. During that year, critical care medicine accounted for 0.56% of GDP,
4.2% of national health expenditure and about 13% of hospital costs.
[2]

Organ systems[edit]
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 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, in general, 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 intensive care unit
(CCU or sometimes CICU, depending on hospital) for heart disease, medical intensive care unit
(MICU), surgical intensive care unit (SICU), pediatric intensive care unit (PICU), neuroscience critical
care unit (NCCU), overnight intensive-recovery (OIR), shock/trauma intensive-care unit (STICU),
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, so intensive care resources (see
below) were brought to the room of the patient that needed the additional monitoring, care, and
resources. It became rapidly evident, however, 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.
Equipment and systems[edit]


An endotracheal tube
Common equipment in an intensive care unit (ICU) includes mechanical ventilation to assist
breathing through an endotracheal tube or atracheotomy; 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.
Medical specialties[edit]
Critical care medicine is a relatively new but increasingly important medical
specialty. Physicians with training in critical care medicine are referred to as intensivists.
[3]
In the
United States, the specialty requires additional fellowship training for physicians having completed
their primary residency training in internal
medicine, pediatrics, anesthesiology, surgery or emergency medicine. US board certification in
critical care medicine is available through all five specialty boards. Intensivists with a primary training
in internal medicine sometimes pursue combined fellowship training in another subspecialty such as
pulmonary medicine, cardiology, infectious disease, or nephrology. The American Society of Critical
Care Medicine is a well-established multiprofessional society for practitioners working in the ICU
including nurses, respriatory therapists, and physicians. Most medical research has demonstrated
that ICU care provided by intensivists produces better outcomes and more cost-effective care.
[4]
This
has led the Leapfrog Group to make a primary recommendation that all ICU patients be managed or
co-managed by a dedicated intensivist who is exclusively responsible for patients in one ICU.
However, in the US, there is a critical shortage of intensivists and most hospitals lack this critical
physician team member.
Other members of the critical care team may also pursue additional training in critical care medicine
as intensivists. Respiratory therapists may pursue additional education and training leading to
credentialing in adult critical care (ACCS) and neonatal and pediatric (NPS) specialties. Nurses may
pursue additional education and training in critical care medicine leading to certification as a CCRN
by the American Association of Critical Care Nurses. Paramedics are certified to levels of CCEMT-P,
PNCCT-P, CCP-C and/or FP-C depending upon their speciality (e.g. air, ground, adult, pediatric
and/or neonatal medicine). Nutrition in the intensive care unit presents unique challenges and critical
care nutrition is rapidly becoming a subspecialty for dieticians who can pursue additional training and
achieve certification in enteral and parenteral nutrition through the American Society for Parenteral
and Enteral Nutrition (ASPEN). Pharmacists may pursue additional training in a postgraduate
residency and become certified as critical care pharmacists.
Patient management in intensive care differs significantly between countries. In countries such as
Australia and New Zealand, where intensive care medicine is a well-established speciality, many
larger ICUs are described as "closed". In a closed unit the intensive care specialist takes on the
senior role where the patient's primary physician now acts as a consultant. The advantage of this
system is a more coordinated management of the patient based on a team who work exclusively in
ICU. Other countries have open ICUs, where the primary physician chooses to admit and, in
general, makes the management decisions. There is increasingly strong evidence that "closed"
intensive care units staffed by intensivists provide better outcomes for patients.
[5][6]

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.
History[edit]
Florence Nightingale era[edit]


Florence Nightingale
The ICU's roots can be traced back to the Monitoring Unit of critical patients through nurse Florence
Nightingale. The Crimean War began in 1853 when Britain, France, and the Ottoman Empire
(Turkey) declared war on Russia. Because of the lack of critical care and the high rate of infection,
there was a high mortality rate of hospitalised soldiers, reaching as high as 40% of the deaths
recorded during the war. Upon arriving, and practicing, the mortality rate fell to 2%. Nightingale
contracted typhoid, and returned in 1856 from the war. A school of nursing dedicated to her was
formed in 1859 in England. The school was recognised for its professional value and technical
calibre, receiving prizes throughout the British government. The school of nursing was established in
Saint Thomas Hospital, as a one-year course, and was given to doctors. It used theoretical and
practical lessons, as opposed to purely academic lessons. Nightingale's work, and the school, paved
the way for intensive care medicine.
Dandy era[edit]
Walter Edward Dandy was born in Sedalia, Missouri. He received his BA in 1907 through
the University of Missouri and his M.D. in 1910 through the Johns Hopkins University School of
Medicine. Dandy worked one year with Dr. Harvey Cushing in the Hunterian Laboratory of Johns
Hopkins before entering its boarding school and residence in the Johns Hopkins Hospital. He
worked in the Johns Hopkins College in 1914 and remained there until his death in 1946. One of the
most important contributions he made for neurosurgery was the air method in ventriculography, in
which the cerebrospinal fluid is substituted with air to help an image form on an X-Ray of the
ventricular space in the brain. This technique was extremely successful for identifying brain injuries.
Dr. Dandy was also a pioneer in the advances in operations for illnesses of the brain affecting the
glossopharyngeal as well as Mnire's syndrome, and he published studies that show that high
activity can cause sciatic pain. Dandy created the first ICU in the world, 03 beds in Boston in 1926.
Ibsen era[edit]
Bjrn Aage Ibsen (19152007) graduated in 1940 from medical school at the University of
Copenhagen and trained in anesthesiology from 1949 to 1950 at the Massachusetts General
Hospital, Boston. He became involved in the 1952 poliomyelitis outbreak in Denmark,
[7]
where 2722
patients developed the illness in a 6-month period, with 316 suffering respiratory or airway paralysis.
Treatment had involved the use of the few negative pressure respirators available, but these
devices, while helpful, were limited and did not protect against aspiration of secretions. Ibsen
changed management directly, instituting protracted positive pressure ventilation by means of
intubation into the trachea, and enlisting 200 medical students to manually pump oxygen and air into
the patients lungs.
[8]
At this time Carl-Gunnar Engstrm had developed one of the first positive
pressure volume controlled ventilators, which eventually replaced the medical students. In this
fashion, mortality declined from 90% to around 25%. Patients were managed in 3 special 35 bed
areas, which aided charting and other management. In 1953, Ibsen set up what became the world's
first Medical/Surgical ICU in a converted student nurse classroom in Kommunehospitalet (The
Municipal Hospital) in Copenhagen,
[7]
and provided one of the first accounts of the management of
tetanus with muscle relaxants and controlled ventilation. In 1954 Ibsen was elected Head of the
Department of Anaesthesiology at that institution. He jointly authored the first known account of ICU
management principles in Nordisk Medicin, September 18, 1958: Arbejdet p en Ansthesiologisk
Observationsafdeling (The Work in an Anaesthesiologic Observation Unit) with Tone Dahl
Kvittingen from Norway. He died in 2007.
Safar era[edit]
The first surgical ICU was established in Baltimore, and, in 1962, in the University of Pittsburgh, the
first Critical Care Residency was established in the United States.
In 1970, the Society of Critical Care Medicine was formed.
[9]

See also[edit]

Medicine portal
Critical care nursing
GOMER
Respiratory monitoring
Notes[edit]
1. Jump up^ Kahn JM, Goss CH, Heagerty PJ, Kramer AA, O'Brien
CR, Rubenfeld GD., JM; Goss, CH; Heagerty, PJ; Kramer, AA;
O'Brien, CR; Rubenfeld, GD (2006). "Hospital volume and the
outcomes of mechanical ventilation". The New England Journal of
Medicine 355(1): 41
50. doi:10.1056/NEJMsa053993 . PMID 16822995.
2. Jump up^ Halpern, Neil A.; Pastores, Stephen M.; Greenstein,
Robert J. (June 2004). "Critical care medicine in the United States
19852000: An analysis of bed numbers, use, and costs". Critical
Care Medicine 32 (6): 1254
1259.doi:10.1097/01.CCM.0000128577.31689.4C . PMID 1518750
2.
3. Jump up^
[dead link]
[1] . Healthcare Financial Management
Association.
4. Jump up^ "Association between Critical Care Physician
Management and Patient Mortality in the Intensive Care
Unit". Annals of Internal Medicine. 3 June 2008. Volume 148, Issue
11. pp. 801809.
5. Jump up^ Manthous CA, Amoateng-Adjepong Y, al-Kharrat T,
Jacob B, Alnuaimat HM, Chatila W, Hall JB., 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". Mayo Clinic
Proceedings (Abstract) 72 (5): 391
9.doi:10.4065/72.5.391 . PMID 9146680.
6. Jump up^ Hanson CW 3rd, Deutschman CS, Anderson HL 3rd,
Reilly PM, Behringer EC, Schwab CW, Price J., 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". Critical Care
Medicine (Abstract) 27(2): 2704. doi:10.1097/00003246-
199902000-00030 . PMID 10075049.
7. ^ Jump up to:
a

b
"The Danish anaesthesiologist Bjrn Ibsen a
pioneer of long-term ventilation on the upper airways, Louise
Reisner-Snlar, 2009" (PDF format; requires Adobe Reader).
8. Jump up^ Reisner-Snlar, Louise (2011). "The Birth of Intensive
Care Medicine: Bjrn Ibsens Records" (PDF format;
requires Adobe Reader).Intensive Care Medicine. Retrieved 2
October 2012.
9. Jump up^ history reference: Brazilian Society of Critical
Care SOBRATI Video:ICU History Historical photos
References[edit]
Intensive Care Medicine by Irwin and Rippe
Civetta, Taylor, and Kirby's Critical Care
The ICU Book by Marino
Procedures and Techniques in Intensive Care Medicine by Irwin
and Rippe
Halpern, NA, Pastores, SM, Greenstein, RJ (June 2004). "Critical
care medicine in the United States 1985-2000: an analysis of bed
numbers, use, and costs.". Critical Care Medicine 32 (6): 1254
9. doi:10.1097/01.CCM.0000128577.31689.4C . PMID 15187502..
History reference:
Brazilian Society of Intensive Care - SOBRATI
History
Society of Critical Care Medicine
Reynolds, H.N.; Rogove, H.; Bander, J.; McCambridge, M. et al.
(December 2011). "A working lexicon for the tele-intensive care unit:
We need to define tele-intensive care unit to grow and understand
it" . Telemedicine and e-Health. 17 (10): 773
783. doi:10.1089/tmj.2011.0045 .
Olson, Terrah; Brasel, Karen; Redmann, Andrew; Alexander, G.;
Schwarze, Margaret (January 2013). "Surgeon-Reported Conflict
With Intensivists About Postoperative Goals of Care" . JAMA
Surgery. 148 (1): 2935. doi:10.1001/jamasurgery.2013.403 .
External links[edit]

Wikimedia Commons has
media related to I ntensive
care medicine.
Society of Critical Care Medicine
Veterinary Emergency And Critical Care Society
ESICM : European Society of Intensive Care Medicine
ESPNIC: The society for paediatric and neonatal intensive care
healthcare professionals in Europe
UK Intensive Care Society
Scottish Intensive Care Society
Hong Kong Society of Critical Care Medicine
Chinese Society of Critical Care Medicine
Taiwan Society of Critical Care Medicine
From Iron Lungs to Intensive Care , Royal Institution debate,
February 2012
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