![]() A patient being managed in an intensive care unit | |
Focus | Organ dysfunction, life support |
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Significant diseases | Respiratory failure, Organ failure, Multiorgan failure |
Specialist | Intensive care physician Critical care physician Intensivist |
Occupation | |
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Occupation type | Specialty |
Activity sectors | Medicine |
Description | |
Education required |
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Fields of employment | Hospitals, Clinics |
Related jobs | Anesthesiologist |
Intensive care medicine, also called critical care medicine, is a medical specialty that deals with seriously or critically ill patients who have, are at risk of, or are recovering from conditions that may be life-threatening. [1] It includes providing life support, invasive monitoring techniques, resuscitation, and end-of-life care. [2] Doctors in this specialty are often called intensive care physicians, critical care physicians, or intensivists.
Intensive care relies on multidisciplinary teams composed of many different health professionals. Such teams often include doctors, nurses, physical therapists, respiratory therapists, and pharmacists, among others. [3] They usually work together in intensive care units (ICUs) within a hospital. [1]
Patients are admitted to the intensive care unit if their medical needs are greater than what the general hospital ward can provide. Indications for the ICU include blood pressure support for cardiovascular instability (hypertension/hypotension), sepsis, post-cardiac arrest syndrome or certain cardiac arrhythmias. [4] Other ICU needs include airway or ventilator support due to respiratory compromise. The cumulative effects of multiple organ failure, more commonly referred to as multiple organ dysfunction syndrome, also requires advanced care. [4] Patients may also be admitted to the ICU for close monitoring or intensive needs following a major surgery. [5]
There are two common ICU structures: closed and open. [5] In a closed unit, the intensivist takes on the primary role for all patients in the unit. [5] In an open ICU, the primary physician, who may or may not be an intensivist, can differ for each patient. [5] [6] There is increasingly strong evidence that closed units provide better patient outcomes. [7] [8] Patient management in intensive care differs between countries. Open units are the most common structure in the United States, but closed units are often found at large academic centers. [5] Intermediate structures that fall between open and closed units also exist. [5]
Intensive care is usually provided 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. [9] The naming is not rigidly standardized, and types of units are dictated by the needs and available resources of each hospital. These include:
Medical studies suggest a relation between ICU volume and quality of care for mechanically ventilated patients. [11] 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. ICU delirium, formerly and inaccurately referred to as ICU psychosis, is a syndrome common in intensive care and cardiac units where patients who are in unfamiliar, monotonous surroundings develop symptoms of delirium (Maxmen & Ward, 1995). This may include interpreting machine noises as human voices, seeing walls quiver, or hallucinating that someone is tapping them on the shoulder. [12] There exists systematic reviews in which interventions of sleep promotion related outcomes in the ICU have proven impactful in the overall health of patients in the ICU. [13]
The English nurse Florence Nightingale pioneered efforts to use a separate hospital area for critically injured patients. During the Crimean War in the 1850s, she introduced the practice of moving the sickest patients to the beds directly opposite the nursing station on each ward so that they could be monitored more closely. [14] In 1923, the American neurosurgeon Walter Dandy created a three-bed unit at the Johns Hopkins Hospital. In these units, specially trained nurses cared for critically ill postoperative neurosurgical patients. [15] [14]
The Danish anaesthesiologist Bjørn Aage Ibsen became involved in the 1952 poliomyelitis epidemic in Copenhagen, where 2722 patients developed the illness in a six-month period, with 316 of those developing some form of respiratory or airway paralysis. [16] Some of these patients had been treated using the few available negative pressure ventilators, but these devices (while helpful) were limited in number and did not protect the patient's lungs from aspiration of secretions. Ibsen changed the management directly by instituting long-term positive pressure ventilation using tracheal intubation, and he enlisted 200 medical students to manually pump oxygen and air into the patients' lungs round the clock. [17] At this time, Carl-Gunnar Engström had developed one of the first artificial positive-pressure volume-controlled ventilators, which eventually replaced the medical students. With the change in care, mortality during the epidemic declined from 90% to around 25%. [18] [19] Patients were managed in three special 35-bed areas, which aided charting medications and other management.
In 1953, Ibsen set up what became the world's first intensive care unit in a converted student nurse classroom in Copenhagen Municipal Hospital. He provided one of the first accounts of the management of tetanus using neuromuscular-blocking drugs and controlled ventilation. [20] The following year, Ibsen was elected head of the department of anaesthesiology at that institution. He jointly authored the first known account of intensive care management principles in the journal Nordisk Medicin, with Tone Dahl Kvittingen from Norway. [21]
For a time in the early 1960s, it was not clear that specialized intensive care units were needed, so intensive care resources 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 dedicated personnel were available provided better care than ad hoc provision of intensive care services spread throughout a hospital. 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. [22]
Monitoring refers to various tools and technologies used to obtain information about a patient's condition. These can include tests to evaluate blood flow and gas exchange in the body, or to assess the function of organs such as the heart and lungs. [23] Broadly, there are two common types of monitoring in the ICU: noninvasive and invasive. [1]
Noninvasive monitoring does not require puncturing the skin and usually does not cause pain. These tools are more inexpensive, easier to perform, and faster to result. [1]
Invasive monitoring generally provides more accurate measurements, but these tests may require blood draws, puncturing the skin, and can be painful or uncomfortable. [1]
Intensive care usually takes a system-by-system approach to treatment. [9] In alphabetical order, the key systems considered in the intensive care setting are: airway management and anaesthesia, cardiovascular system, central nervous system, endocrine system, gastro-intestinal tract (and nutritional condition), hematology, integumentary system, microbiology (including sepsis status), renal (and metabolic), and respiratory system.
A wide array of drugs including but not limited to: inotropes such as Norepinephrine, sedatives such as Propofol, analgesics such as Fentanyl, neuromuscular blocking agents such as Rocuronium and Cisatracurium as well as broad spectrum antibiotics.
Interventions such as early mobilization or exercises to improve muscle strength are sometimes suggested. [24] [25]
Intensive care units are associated with increased risk of various complications that may lengthen a patient's hospitalization. [9] Common complications in the ICU include:
ICU care requires more specialized patient care; this need has led to the use of a multidisciplinary team to provide care for patients. [4] [1] Staffing between Intensive care units by country, hospital, unit, or institution. [5]
Critical care medicine is an increasingly important medical specialty. Physicians with training in critical care medicine are referred to as intensivists. [26]
Most medical research has demonstrated that ICU care provided by intensivists produces better outcomes and more cost-effective care. [27] 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.
In Australia, the training in intensive care medicine is through College of Intensive Care Medicine.
In Germany, the German Society of Anaesthesiology and Intensive Care Medicine is a medical association of professionals in the anesthetics and intensive care fields. It was established in 1955 by members of the German Society of Surgery.
In the UK, doctors can only enter intensive care medicine training after completing two foundation years and core training in either emergency medicine, anaesthetics, acute medicine or core medicine. Most trainees dual train with one of these specialties; however, it has recently become possible to train purely in intensive care medicine. It has also possible to train in sub-specialties of intensive care medicine including pre-hospital emergency medicine.
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 multi professional society for practitioners working in the ICU including nurses, respiratory therapists, and physicians.
Intensive care physicians have some of the highest percentages of physician burnout among all medical specialties, at 48 percent. [28]
In South Africa
Intensive care training is provided as a fellowship and is awarded as a Sub-Specialty certificate of Critical Care (Cert. Critical Care) which is awarded by the Colleges of Medicine of South Africa. Candidates are eligible to enter sub specialty training after completing specialty training in Anaesthetics, Surgery, Internal Medicine, Obstetrics and Gynaecology, Paediatrics, Cardiothoracic surgery or Neurosurgery.
Training usually takes place over 2 years during which time candidates rotate through different ICU's (Medical, Surgical, Paediatric etc.)
Nurses that work in the critical care setting are typically registered nurses. [5] 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 a standard that was begun in 1975. [29] These certifications became more specialized to the patient population in 1997 by the American Association of Critical care Nurses, to include pediatrics, neonatal and adult. [29]
Nurse practitioners and physician assistants are other types of non-physician providers that care for patients in ICUs. [4] These providers have fewer years of in-school training, typically receive further clinical on the job education, and work as part of the team under the supervision of physicians.
Critical care pharmacists work with the medical team in many aspects, but some include, monitoring serum concentrations of medication, past medication use, current medication use, and medication allergies. [6] Their typically round with the team, but it may differ by institution. [6] Some pharmacist after attaining their doctorate or pharmacy may pursue additional training in a postgraduate residency and become certified as critical care pharmacists. [6] Pharmacists help manage all aspects of drug therapy and may pursue additional credentialing in critical care medicine as BCCCP by the Board of Pharmaceutical Specialties. Many critical care pharmacists are a part of the multi-professional Society of Critical Care Medicine. [6] Inclusion of pharmacist decreases drug reactions and poor outcomes for patients. [4]
Nutrition in intensive care units presents unique challenges due to changes in patient metabolism and physiology while critically ill. [30] 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).
Respiratory therapists often work in intensive care units to monitor how well a patient is breathing. [31] Respiratory therapists may pursue additional education and training leading to credentialing in adult critical care (ACCS) and neonatal and pediatric (NPS) specialties. Respiratory therapists have been trained to monitor a patient's breathing, provide treatments to help their breathing, evaluate for respiratory improvement, and manage mechanical ventilation parameters. [31] They may be involved in emergency care like inserting and managing an airway, humidification of oxygen, administering diagnostic lung mechanics tests, invasive or non-invasive mechanical ventilation management, weaning the ventilator, aerosol therapy (pulmonary vasodilatory medications included), inhaled Nitric oxide therapy, arterial blood gas analysis, and providing physiotherapy. Additionally, Respiratory Therapists are commonly involved in ECMO management and many pursue certification in such therapies due to the intimate relationship of the heart and lungs. On-going critical care management of an ECMO patient commonly requires strict ventilator management in relation to the type of ECMO support used. [32]
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$19–55 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. [33] In 2011, hospital stays with ICU services accounted for just over one-quarter of all discharges (29.9%) but nearly one-half of aggregate total hospital charges (47.5%) in the United States. The mean hospital charge was 2.5 times higher for discharges with ICU services than for those without. [34]
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: CS1 maint: location missing publisher (link) CS1 maint: others (link)A respiratory therapist is a specialized healthcare practitioner trained in critical care and cardio-pulmonary medicine in order to work therapeutically with people who have acute critical conditions, cardiac and pulmonary disease. Respiratory therapists graduate from a college or university with a degree in respiratory therapy and have passed a national board certifying examination. The NBRC is responsible for credentialing as a CRT, or RRT,
A ventilator is a type of breathing apparatus, a class of medical technology that provides mechanical ventilation by moving breathable air into and out of the lungs, to deliver breaths to a patient who is physically unable to breathe, or breathing insufficiently. Ventilators may be computerized microprocessor-controlled machines, but patients can also be ventilated with a simple, hand-operated bag valve mask. Ventilators are chiefly used in intensive-care medicine, home care, and emergency medicine and in anesthesiology.
Mechanical ventilation or assisted ventilation is the medical term for using a machine called a ventilator to fully or partially provide artificial ventilation. Mechanical ventilation helps move air into and out of the lungs, with the main goal of helping the delivery of oxygen and removal of carbon dioxide. Mechanical ventilation is used for many reasons, including to protect the airway due to mechanical or neurologic cause, to ensure adequate oxygenation, or to remove excess carbon dioxide from the lungs. Various healthcare providers are involved with the use of mechanical ventilation and people who require ventilators are typically monitored in an intensive care unit.
Anesthesiology, anaesthesiology, or anaesthesia is the medical specialty concerned with the total perioperative care of patients before, during and after surgery. It encompasses anesthesia, intensive care medicine, critical emergency medicine, and pain medicine. A physician specialized in anesthesiology is called an anesthesiologist, anaesthesiologist, or anaesthetist, depending on the country. In some countries, the terms are synonymous, while in other countries, they refer to different positions and anesthetist is only used for non-physicians, such as nurse anesthetists.
A neonatal intensive care unit (NICU), also known as an intensive care nursery (ICN), is an intensive care unit (ICU) specializing in the care of ill or premature newborn infants. The NICU is divided into several areas, including a critical care area for babies who require close monitoring and intervention, an intermediate care area for infants who are stable but still require specialized care, and a step down unit where babies who are ready to leave the hospital can receive additional care before being discharged.
A bag valve mask (BVM), sometimes known by the proprietary name Ambu bag or generically as a manual resuscitator or "self-inflating bag", is a hand-held device commonly used to provide positive pressure ventilation to patients who are not breathing or not breathing adequately. The device is a required part of resuscitation kits for trained professionals in out-of-hospital settings (such as ambulance crews) and is also frequently used in hospitals as part of standard equipment found on a crash cart, in emergency rooms or other critical care settings. Underscoring the frequency and prominence of BVM use in the United States, the American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiac Care recommend that "all healthcare providers should be familiar with the use of the bag-mask device." Manual resuscitators are also used within the hospital for temporary ventilation of patients dependent on mechanical ventilators when the mechanical ventilator needs to be examined for possible malfunction or when ventilator-dependent patients are transported within the hospital. Two principal types of manual resuscitators exist; one version is self-filling with air, although additional oxygen (O2) can be added but is not necessary for the device to function. The other principal type of manual resuscitator (flow-inflation) is heavily used in non-emergency applications in the operating room to ventilate patients during anesthesia induction and recovery.
Ventilator-associated pneumonia (VAP) is a type of lung infection that occurs in people who are on mechanical ventilation breathing machines in hospitals. As such, VAP typically affects critically ill persons that are in an intensive care unit (ICU) and have been on a mechanical ventilator for at least 48 hours. VAP is a major source of increased illness and death. Persons with VAP have increased lengths of ICU hospitalization and have up to a 20–30% death rate. The diagnosis of VAP varies among hospitals and providers but usually requires a new infiltrate on chest x-ray plus two or more other factors. These factors include temperatures of >38 °C or <36 °C, a white blood cell count of >12 × 109/ml, purulent secretions from the airways in the lung, and/or reduction in gas exchange.
An intensivist, also known as a critical care doctor, is a medical practitioner who specializes in the care of critically ill patients, most often in the intensive care unit (ICU). Intensivists can be internists or internal medicine sub-specialists, anaesthesiologists, emergency medicine physicians, paediatricians, or surgeons who have completed a fellowship in critical care medicine. The intensivist must be competent not only in a broad spectrum of conditions among critically ill patients but also with the technical procedures and equipment used in the intensive care setting such as airway management, rapid sequence induction of anaesthesia, maintenance and weaning of sedation, central venous and arterial catheterisation, renal replacement therapy and management of mechanical ventilators.
An intensive care unit (ICU), also known as an intensive therapy unit or intensive treatment unit (ITU) or critical care unit (CCU), is a special department of a hospital or health care facility that provides intensive care medicine.
Critical care nursing is the field of nursing with a focus on the utmost care of the critically ill or unstable patients following extensive injury, surgery or life-threatening diseases. Critical care nurses can be found working in a wide variety of environments and specialties, such as general intensive care units, medical intensive care units, surgical intensive care units, trauma intensive care units, coronary care units, cardiothoracic intensive care units, burns unit, paediatrics and some trauma center emergency departments. These specialists generally take care of critically ill patients who require mechanical ventilation by way of endotracheal intubation and/or titratable vasoactive intravenous medications.
The Critical Care Air Transport Team (CCATT) concept dates from 1988, when Col. P.K. Carlton and Maj. J. Chris Farmer originated the development of this program while stationed at U.S. Air Force Hospital Scott, Scott Air Force Base, Illinois. Dr. Carlton was the Hospital Commander, and Dr. Farmer was a staff intensivist. The program was developed because of an inability to transport and care for a patient who became critically ill during a trans-Atlantic air evac mission in a C-141. They envisioned a highly portable intensive care unit (ICU) with sophisticated capabilities, carried in backpacks, that would match on-the-ground ICU functionality.
Neurocritical care is a medical field that treats life-threatening diseases of the nervous system and identifies, prevents, and treats secondary brain injury.
Geriatric intensive care unit is a special intensive care unit dedicated to management of critically ill elderly.
A pediatric intensive care unit, usually abbreviated to PICU, is an area within a hospital specializing in the care of critically ill infants, children, teenagers, and young adults aged 0–21. A PICU is typically directed by one or more pediatric intensivists or PICU consultants and staffed by doctors, nurses, and respiratory therapists who are specially trained and experienced in pediatric intensive care. The unit may also have nurse practitioners, physician assistants, physiotherapists, social workers, child life specialists, and clerks on staff, although this varies widely depending on geographic location. The ratio of professionals to patients is generally higher than in other areas of the hospital, reflecting the acuity of PICU patients and the risk of life-threatening complications. Complex technology and equipment is often in use, particularly mechanical ventilators and patient monitoring systems. Consequently, PICUs have a larger operating budget than many other departments within the hospital.
Bjørn Aage Ibsen was a Danish anesthetist and founder of intensive-care medicine.
Modes of mechanical ventilation are one of the most important aspects of the usage of mechanical ventilation. The mode refers to the method of inspiratory support. In general, mode selection is based on clinician familiarity and institutional preferences, since there is a paucity of evidence indicating that the mode affects clinical outcome. The most frequently used forms of volume-limited mechanical ventilation are intermittent mandatory ventilation (IMV) and continuous mandatory ventilation (CMV). There have been substantial changes in the nomenclature of mechanical ventilation over the years, but more recently it has become standardized by many respirology and pulmonology groups. Writing a mode is most proper in all capital letters with a dash between the control variable and the strategy.
Prone ventilation, sometimes called prone positioning or proning, is a method of mechanical ventilation with the patient lying face-down (prone). It improves oxygenation in most patients with acute respiratory distress syndrome (ARDS) and reduces mortality. The earliest trial investigating the benefits of prone ventilation occurred in 1976. Since that time, many meta-analyses and one randomized control trial, the PROSEVA trial, have shown an increase in patients' survival with the more severe versions of ARDS. There are many proposed mechanisms, but they are not fully delineated. The proposed utility of prone ventilation is that this position will improve lung mechanics, improve oxygenation, and increase survival. Although improved oxygenation has been shown in multiple studies, this position change's survival benefit is not as clear. Similar to the slow adoption of low tidal volume ventilation utilized in ARDS, many believe that the investigation into the benefits of prone ventilation will likely be ongoing in the future.
The Society of Intensive Care Medicine (SICM) is the representative body for Intensive Care Medicine (ICM) professionals in Singapore.
Proning or prone positioning is the placement of patients into a prone position so that they are lying on their front. This is used in the treatment of patients in intensive care with acute respiratory distress syndrome (ARDS). It has been especially tried and studied for patients on ventilators but, during the COVID-19 pandemic, it is being used for patients with oxygen masks and CPAP as an alternative to ventilation.