Intensive care medicine
Intensive Care Medicine or critical care medicine is concerned with providing greater than ordinary medical care and observation to people in a critical or unstable condition.
People requiring intensive care include those after major surgery, with severe head trauma, life-threatening acute illness, respiratory insufficiency, coma, haemodynamic insufficiency, severe fluid imblance or with the failure of one or more of the major organ systems (life-critical systems or others).
It is generally the most expensive, high technology and resource intensive area of medical care. In the United States estimates of the 2000 expenditure for critical care medicine ranged from US$15-55 billion. This is about 0.5% of GDP and about 13% of national health care expenditure (Halpern, 2004).
Intensive care is only offered to those whose condition is potentially reversible and who have a good chance of surviving with intensive care support. Since the critically ill are close to dying the outcome of this intervention is difficult to predict. Many patients therefore still die in the Intensive Care Unit. A prime requisite for admission to an Intensive Care Unit is that the underlying condition can be overcome. Therefore treatment is merely meant to win time in which the acute infliction can be resolved.
Organ Systems
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 obervation-intervention-impression basis to produce a daily plan. As well as the key systems Intensive care treatment also 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), haematology, microbiology (including sepsis status), peripheries (and skin), renal (and metabolic), respiratory system.
The provision of intensive care is generally administered in a specialized unit of a hospital called the Intensive Care Unit (ICU) or Critical Care Unit (CCU). Many hospitals also have designated intesive care areas for certain specialities of medicine, such as the Coronary Care Unit (CCU) for heart disease, Medical Intesive Care Unit (MICU), Surgical Intensive Care Unit (SICU), Pediatric Intensive Care Unit (PICU), Neuroscience Critical Care (NCCU), Overnight Intensive Recovery (OIR), Neuro/Neonatal Intensive Care Unit (NICU), 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 1960's it was not clear that specialized intensive care units were needed and intensive care resources (see below) were brough to the room of the patient who needed the additional nursing care and resources. It became rapidly evident, though, that a set location where intensive care resources and personnel were available provided better care than ad hoc provision of intensive care services spread throughout a hospital.
Common equipment in an intensive care unit (ICU) includes mechanical ventilation to assist breathing through an endotracheal tube or a tracheotomy opening; dialysis equipment for renal problems; equipment for the constant monitoring of bodily functions; a web of intravenous lines, feeding tubes, nasogastric tubes, suction pumps, drains and catheters; and a wide array of drugs to treat the main condition(s), induce sedation, reduce pain, and prevent secondary infections.
Physicians that practice in an intensive care unit historically have been the same physicians that care for the patient before transferring to the ICU. This is still commonly the case. In some hospitals there is a special group of physicians that staff the ICU, known as Intensivists, which is becoming a speciality. Whether the intensivist becomes the lead doctor or a consultant on a case is a matter of policy in each hospital. The speciality is unusual among the specialties of medicine in that their backgrounds may be Pulmonary, Anesthesiology, Internal Medicine, or other specialties. The reason for the high representation of Pulmonary and Anesthesiology is the need to be familiar with ventilator management. Although ventilating generally healthy individuals in the case of sugery is entirely different from ventilating in case of respiratory insufficiency. Therefore a new type of specialist was needed: the intensivist.
Benchmarking
In order to discriminate patients or benchmark the performance of intensive care units, several ICU scoring systems have been invented.
References
- Intensive Care Medicine by Irwin and Rippe
- The ICU Book by Marino
- Procedures and Techniques in Intensive Care Medicine by Irwin and Rippe
- Halpern NA, Pastores SM, Greenstein RJ. Critical care medicine in the United States 1985-2000: an analysis of bed numbers, use, and costs. Crit Care Med 2004;32:1254-9. PMID 15187502.
