Intensive care medicine

The Intensive Care Medicine is a medical specialty that deals with diagnosis and treatment of life-threatening conditions and diseases. This happens mostly in dedicated stations of a hospital ( intensive care unit ), which are conducted by specially trained medical specialists, such as anesthesiologists, internists, surgeons, pediatricians or neurologists.

Intensive care units are structurally and technically complex equipment equipped. Due to the high complexity care here is a caregiver for 1-3 patients in charge (on " normal stations " is the ratio about 1:20 ).

The treatment of patients in the emergency medicine also often wears the characteristics of intensive care medicine.

• 3.1 Clinical monitoring
• 3.2 Technical Monitoring

History

The ICU has its historical roots in anesthesiology, as a founding father of the first intensive care unit is commonly the Danish anaesthesiologist Björn Ibsen. In 1954, Ibsen the first intensive care unit in Copenhagen, as a direct result of the great polio epidemic of 1952. The long-term ventilation of patients was the original reason that such elaborate methods and facilities have been created. Another precursor of today's ICUs were the coronary care units ( CCU). These were stations for ECG monitoring of patients with myocardial infarction with the possibility of ventricular fibrillation or ventricular defibrillation. They were from one of the inventors of the defibrillation, the American Bernard Lown, propagated.

Disease spectrum

In intensive care patients are admitted whose state is threatening or whose conditions could be threatening. So not only lead serious diseases, but also conditions for large and strong meshing operations to intensive medical monitoring, and treatment. Principle must be given a certain favorable prognosis of the disease condition.

Findings include intensive medical treatment according to the basic disease a large wingspan. The goal is the restoration of the full health or at least the achievement of a largely autonomous state of patients. So-called life-prolonging measures, which therefore have no end in itself.

The increase of process, structure and outcome in intensive care is associated with a wider use of methods.

Terminal illnesses, such as terminal cancer, do not lead to admission to the ICU. In this area, palliative care is established.

Elementary disturbances

• Disorders of the respiratory (among ARDS, pulmonary edema )
• Severe electrolyte disturbances
• Disorders of hemostasis ( blood clotting)
• Shock ( including anaphylactic shock, hypovolämer S., neurogenic S., cardiogener S., septic p )
• Severe disorders of consciousness

Complex diseases

• Sepsis, SIRS
• Multi-organ failure, MOF, MODS
• Respiratory failure, ARDS, respiratory failure, pulmonary embolism, pulmonary edema
• Acute renal failure (up to 30 % of ICU patients are primarily or secondarily affected)
• Circulatory shock in various forms: hemorrhagic shock, septic shock, hypovolemic shock, neurogenic shock
• Requiring monitoring post-operative conditions (eg after heart surgery )
• Severe heart disease (myocardial infarction, congestive heart failure)
• Dangerous heart rhythm (arrhythmia )
• Severe neurological diseases: stroke ( treatment on special stroke units ), cerebral hemorrhage, subarachnoid hemorrhage, Guillain -Barré syndrome, severe meningitis, myastenische crises, delirium, delirium tremens
• Severe craniocerebral trauma
• Multiple trauma and other life-threatening injuries
• Severe peritonitis
• Acute pancreatitis
• Severe poisoning
• Severe systemic infections

Monitoring methods

The state hard ill patients can change rapidly. Take this fact into standardized monitoring measures. The monitoring can be divided into methods without and with technical assistance:

Clinical monitoring

Requirement of sufficient monitoring is in each case the personal observation by the care or medical personnel, including a huge bedside documentation requirement contributes.

To assess the state of consciousness missing today usually technical tools so that nerve monitoring in accordance with recognized and standardized verbal stages and state organizations takes place (eg, Glasgow Coma Scale [ GCS ] in brain traumas, which indexing provides the basis of a verbal status description of the patient). For the assessment of pain verbal rating scales (VRS ) can be used or visual analog scales (VAS ).

Technical Monitoring

In the ICU, patients are also monitored continuously by the staff through vital signs monitors and patient monitors. In addition to continuous monitoring with alarm forwarding the technical methods also permit more extensive standardization for the measurement acquisition as subjective errors are largely excluded. Furthermore, to the vital signs monitors interfaces through which the measured values ​​can be read and automatically documented in a patient data management system.

The measurement methods, a distinction between non- invasive and invasive methods. For the invasive monitoring of a parameter, the body surface to be pierced, for example in the form of catheters, which are inserted into the large veins of the body by any means. This procedure always involves a certain risk, either through infection or induction of bleeding. The strategic objective of the technical development will always be the non-invasive determination of measured values ​​.

Basic non-invasive monitoring methods are concerned with the monitoring of cardiovascular and respiratory systems. Since it is non-invasive methods for the derivation of the ECG, the monitoring of blood pressure, body temperature, and the oxygen saturation of the blood, there is hardly any patient in an intensive care unit, where these measurements are not made.

To the invasive, generally wider, but also komplikationsträchtigeren method involves measurement of the central venous pressure, arterial blood pressure measurement and the use of the pulmonary artery catheter. With the latter method, parameters can be measured, from which can be, for example, the oxygen utilization of the circulating blood and the pumping function of the heart identify with cardiac output. The process is relatively risky, as there is a mechanical irritation of the heart, cardiac arrhythmias may cause. Currently less risky methods are introduced, which can replace the Pulmonalkatheter in certain indications.

Thanks to modern technological development increasingly hold lab machines feed in intensive care units. This allows frequently used values ​​, such as blood gases, acid -base status, electrolytes, hemoglobin bedside and are thus determined quickly ( point-of- care testing ).

Methods are supplemented by imaging methods such as x-ray diagnosis ( for example, to assess the lung ), and ultrasound, which are carried out usually in the intensive care unit. Tests, such as CT or MRI are carried out in special compartments ( X-ray department ). For this purpose, the patient to be transported, if necessary with the mobile processing units (for example, respirators ) for the respective large-scale equipment. Even in this situation outside the mobile station must not remove the monitoring and quality of care of patients.

A method list is also located here.

Therapy methods

There are among other things used:

• Artificial respiration
• Infusion, transfusion therapy
• Continuous drug therapy by syringe pumps ( eg catecholamines )
• Dialysis, hemofiltration
• Artificial nutrition
• Defibrillation
• ECMO ( extracorporeal membrane oxygenation )

Hygiene and Infection

Patients in intensive care facilities have a five-to tenfold increased risk of infection to patients from general wards. In critically ill patients, add different infektionsbegünstigende factors that emanate both from the patients themselves, as well as treatment measures.

Patient side lead especially the underlying disease and comorbidities in a weakening of the immune status. Infektionsbegünstigend also seem a poor nutritional status, advanced age ( statistically speaking ), and disturbances of consciousness.

Therapy side break through a number of measures the natural immune barrier of the pre-damaged organism. Causes and consequences can be:

• Ventilation: Tracheo-/Bronchitiden and pneumonia are transported through damage to the tracheal and bronchial mucosa of Clearancefunktion.
• Central vascular access: By eliminating the continuity of the skin its protective function is lost. Result is usually a sepsis.
• Access to body cavities: In the same sense as in the respiration are feeding tubes and urinary bladder catheter entry sites for pathogens.
• Special therapies: By increasing the gastric juice pH value in the context of the so-called " Stressulcusprophylaxe " is repealed its disinfecting action. This leads to the spread of germs in the gastrointestinal tract ( Intestinuum ). The colonization by pathogenic germs can lead to functional limitation and failure of the intestine.
• Chemotherapy: a result of the accompanying immunosuppression may be a sepsis.

Patients after bone marrow transplantation are at risk of infection by the necessary immunosuppression in a high degree.

In the intensive care patients must be treated increasingly infected with germs that are resistant to commonly used antibiotics treatments ( for example, oxacillin or methicillin- resistant Staphylococcus aureus).

Been estimated that two-thirds of all infections acquired in the ward ( nosocomial infection). For these reasons, specific hygiene measures required in intensive care units to reduce the risk of infection:

• Structural measures: The stations are equipped with a lock system, can change their clothes in the staff and visitors.
• Area Clothing: The staff wears special clothing that is worn only within the ICU.
• Hand Hygiene: The hands of the staff have been found to be the largest transmission reservoir. Therefore, a hand sanitizer is often necessary when working on patients.
• Droplet infection: When working with especially immunocompromised patients wear a face mask must be worn.
• Isolation: Patients with extremely weakened immune status (bone marrow transplantation) must be isolated for their own protection. In contrast, patients with multi-resistant bacteria (MRSA, see above) to protect the environment isolated. Many interdisciplinary ICUs have for latter patients about special rooms that have a private lock system.

There are also a number of useful therapeutic measures that aim to support normal body functions explicitly, such as extensive waiver of parenteral nutrition.

Among the encountered in intensive care circumstances, apply also under hygienic side, a constant trade-off between necessary and often life-sustaining measures and their side effects.