MONITORING OF CRITICALLY ILL PATIENT

Presented by:

Introduction
In a critically ill patient, the history is often incomplete, physical examinations are frequently inconclusive and the signs on which the clinical diagnosis depend often disappear when the patient approaches death making the diagnosis difficult to establish. So, management of these patients in general wards becomes difficult. An Intensive Care Unit (ICU) is fully equipped with monitoring and technical facilities and patient can receive continuous expert nursing care and the constant attention of appropriately trained medical staffs, which is not possible in general wards.

Objectives while managing these patients:

To sustain life. To prevent, reverse or minimize damage to vital organs.

Whom to label as Critically Ill?

The identification of the at risk patient or those patient who could benefit from intensive care treatment is largely based on scoring systems. The most frequently used scoring system is APACHE II (Acute Physiology Assessment and Chronic Health Evaluation), which is based on evaluation of 12 physiological variables which are altered in response to stress or disease process. The physiological parameters are: 1. 2. 3. 4. 5. 6. 7. 8. 9. Temperature - core Mean arterial pressure Heart rate Respiratory rate. Oxygenation Arterial pH Serum sodium Serum potassium Serum creatinine 10. Hematocrit. 11. White blood cell count. 12. Glasgow coma score.

Monitoring of critically ill

Monitoring of physiological responses to stress or disease not only allows the assessment of the physiological reserve of the patient but will also give a baseline against which the effectiveness of any applied treatment can be judged. No single parameter is significant. Changing parameters of trends are more significant.

Monitoring of Cardiovascular System:

1. ECG: Gives information about rate and rhythm changes, but is not useful to monitor ischaemic changes. Modified form lead CM5 can be used to detect both ischaemic changes and arrhythmias. Blood pressure: May be monitored intermittently with sphygmomanometer. Continuous monitoring with line placed in radial artery is preferable.

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Central Venous Pressure (CVP): Monitored by placing a catheter in either subclavian or internal jugular vein. Useful means of assessing the circulating volume and determining the appropriate rate of intravenous fluid replacement. Pulmonary Artery Occlusion Pressure (PAOP): More beneficial than CVP in critically ill patient, right ventricular dysfunction and pulmonary vascular disease. Measures the left ventricular end diastolic pressure. Cardiac Output: Most commonly measured by thermodilution technique. Cold 5% Dextrose is injected in central vein and after admixture with total venous return in right ventricle, temperature of blood is measured in pulmonary artery with a thermistor. Fluid balance: By maintaining strict input/output chart

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Monitoring of CVP

Gastric tonometry

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Temperature: Gradient between core and peripheral temperature is a better indicator of peripheral perfusion. Haematocrit and Haemoglobin concentration: Hct of 35% and Hb% of 12-14 gm/dl is thought to be optimal because reduction of viscosity of blood is thought to enhance tissue perfusion. Gastric tonometry: Indirect means to measure gastric mucosal intracellular pH. PCO2 of gastric content is estimated using a silicon balloon attached to the tip of nasogastic tube. (Since PCO2 of luminal content is thought to equilibriate with gastric mucosal intracellular PCO2). Localised intracellular acidosis may be due to: Decreased oxygen supply to these cells. Impaired oxygen utilization by these cells. May be the earliest index of impaired core tissue perfusion with oliguria and arterial acidaemia developing later on.

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Monitoring of Respiratory System:

1. 2. Oxygen saturation by Pulse Oximetry: Probe is attached to finger or ear lobule. Spectrophotometric analysis. Normal >97%. Not effective when peripheral perfusion is reduced. Cannot differentiate Carboxyhaemoglobin form Oxyhaemoglobin. Arterial blood gas analysis: Especially beneficial in ventilated patient. Helps to adjust inspired oxygen and minute volume to achieve a desired PaO2 an PaCO2 respectively. Also useful to monitor acid-base balance.

Monitoring of Renal System:

1. 2. Urinary flow: Sensitive measure of renal perfusion. Measured by simply placing a self retaining catheter. Should not fall below 0.5ml/kg body weight/hour. Serum Electrolytes, Urea and Creatinine

Monitoring of Central Nervous System:

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Intracranial pressure (ICP):

Normal <10mm of Hg. Indicated in patients with head injury, subarachnoid haemorrhage, hepatic encephalopathy, brain tumours and encephalitis. Made by placing a device within a cranial vault by making a small burr hole in parietal or frontal areas of non dominant hemisphere. Cerebral oedema and haemorrhage causes a rapid rise in ICP. ICP above 20-25 mm of Hg warrants immediate correction.

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Cerebral function monitor (CFM): Compact form or EEG where unwanted frequencies are filtered. Indicated during carotid artery surgery and those who are likely to develop convulsions.

Monitoring of Haematological parameters:

1. Assessment of Clotting function: For those who develop haemostatic failure and acquired coagulopathies. Prothrombin time, Activated Partial Thromboplastin Time (APTT), Fibrin Degradation Products (FDP) or D-dimer.

Conclusion:
Different patients respond to a similar insult in different ways and have different physiological reserves. Assessment of physiological status is important in allowing these differences to be appreciated. In addition, many of the treatment options we use in the critically ill patient require some form of physiological monitoring for us to gauge their effectiveness, which is the main aim of meticulous monitoring of these paitents.

References:
1. Davidsons Principles and Practice of Medicine 18th Edition. 2. Clinical Medicine by Parveen Kumar & Michael Clark 3rd Edition. 3. Website http://www.rcsed.ac.uk/journal/vol44_6/446 0010.htm