admission criteria to the intensive care unit د. ماجد عمر القطان إختصاصي طب...

ADMISSION CRITERIAADMISSION CRITERIA TOTO THE INTENSIVE CARE THE INTENSIVE CARE

UNITUNIT

القطان. عمر ماجد القطان. د عمر ماجد د

طوارئ طب طوارئ إختصاصي طب إختصاصي

The Intensive Care Unit is an The Intensive Care Unit is an expensive resource area and expensive resource area and should be reserved forshould be reserved forpatients with reversible patients with reversible medical conditions with a medical conditions with a reasonable prospect ofreasonable prospect ofsubstantial recoverysubstantial recovery

CLINICAL EXAMINATION OF THE CRITICALLY ILL CLINICAL EXAMINATION OF THE CRITICALLY ILL PATIENTPATIENT

Recognising the critically ill Recognising the critically ill patientpatientCardiovascular Cardiovascular

signssigns• • Cardiac arrestCardiac arrest• • Pulse rate <40 or Pulse rate <40 or

>140 bpm>140 bpm• • Systolic blood Systolic blood

pressurepressure(BP) <100 mmHg(BP) <100 mmHg• • Tissue hypoxiaTissue hypoxiaPoor peripheral Poor peripheral

perfusionperfusionMetabolic acidosisMetabolic acidosisHyperlactataemiaHyperlactataemia

• • Poor response to Poor response to volumevolume

resuscitationresuscitation• • Oliguria: <0.5 Oliguria: <0.5

ml/kg/hrml/kg/hr(check urea, (check urea,

creatinine, K+)creatinine, K+)

Respiratory signsRespiratory signs • •Threatened or obstructed airwayThreatened or obstructed airway

• •Stridor, intercostal recessionStridor, intercostal recession • •Respiratory arrestRespiratory arrest

• •Respiratory rate < 8 or > 35/minRespiratory rate < 8 or > 35/min • •Respiratory ‘distress’: use ofRespiratory ‘distress’: use of

accessory muscles; unable toaccessory muscles; unable tospeak in complete sentencesspeak in complete sentences

• •SpSpO2 < 90% on high-flow O2O2 < 90% on high-flow O2 • •Rising Rising PaPaCO2 > 8 kPa (> 60 mmHg)CO2 > 8 kPa (> 60 mmHg),,

or > 2 kPa (> 15 mmHg) aboveor > 2 kPa (> 15 mmHg) above‘‘normal’ with acidosisnormal’ with acidosis

Neurological signs1 .Severe head trauma

2 .Status epilepticus3 .Meningitis with altered mental status or

respiratory compromise4 .Acutely altered sensorium with the

potential for airway compromise5 .Progressive neuromuscular dysfunction

requiring respiratory support and / or cardiovascular monitoring

(myasthenia gravis, Gullain- Barre syndrome)

6 .Brain dead or potentially brain dead patients who are being aggressively managed while determining organ donation status

Indications for considering Indications for considering renal replacement therapyrenal replacement therapy

• Oliguria Oliguria ((<0.5ml<0.5ml//kgkg//hh))• Life threatening hyperkalaemia (>6 Life threatening hyperkalaemia (>6

mmol/l) resistant to drug treatmentmmol/l) resistant to drug treatment• Rising plasma concentrations of urea Rising plasma concentrations of urea

or creatinine, or bothor creatinine, or both• Severe metabolic acidosisSevere metabolic acidosis• Symptoms related to uraemia (for Symptoms related to uraemia (for

example, pericarditis, encephalopathy)example, pericarditis, encephalopathy)

EndocrineEndocrine• 1. Diabetic ketoacidosis complicated 1. Diabetic ketoacidosis complicated

by haemodynamic instability, alteredby haemodynamic instability, altered• mental statusmental status• 2. Severe metabolic acidotic states2. Severe metabolic acidotic states• 3. Thyroid storm or myxedema coma 3. Thyroid storm or myxedema coma

with haemodynamic instabilitywith haemodynamic instability• 4. Hyperosmolar state with coma 4. Hyperosmolar state with coma

and/or haemodynamic instabilityand/or haemodynamic instability• 5. Adrenal crises with haemodynamic 5. Adrenal crises with haemodynamic

instabilityinstability

EndocrineEndocrine

• 6. Other severe electrolyte 6. Other severe electrolyte abnormalities, such as:abnormalities, such as:

- Hypo or hyperkalemia with - Hypo or hyperkalemia with dysrhythmias or muscular weaknessdysrhythmias or muscular weakness

- Severe hypo or hypernatremia with - Severe hypo or hypernatremia with seizures, altered mental statusseizures, altered mental status

- Severe hypercalcemia with altered - Severe hypercalcemia with altered mental status, requiringmental status, requiring

haemodynamic monitoringhaemodynamic monitoring

GastrointestinalGastrointestinal

•1. Life threatening 1. Life threatening gastrointestinal bleedinggastrointestinal bleeding

•2. Acute hepatic failure 2. Acute hepatic failure leading to coma, leading to coma, haemodynamic instabilityhaemodynamic instability

•3. Severe acute pancreatitis3. Severe acute pancreatitis

HaematologyHaematology

•1. Severe coagulopathy and/or 1. Severe coagulopathy and/or bleeding diasthesisbleeding diasthesis

•2. Severe anemia resulting in 2. Severe anemia resulting in haemodynamic and/or respiratoryhaemodynamic and/or respiratory

compromisecompromise•3. Severe complications of sickle 3. Severe complications of sickle

cell crisiscell crisis•4. Haematological malignancies 4. Haematological malignancies

with multi-organ failurewith multi-organ failure

Multi-systemMulti-system• 1. Severe sepsis or septic shock1. Severe sepsis or septic shock• 2. Multi-organ dysfunction syndrome2. Multi-organ dysfunction syndrome• 3. Polytrauma3. Polytrauma• 4. Dengue haemorrhagic fever/dengue 4. Dengue haemorrhagic fever/dengue

shock syndromeshock syndrome• 5. Drug overdose with potential acute 5. Drug overdose with potential acute

decompensation of major organdecompensation of major organ• systemssystems• 6. Environmental injuries (lightning, 6. Environmental injuries (lightning,

near drowning, hypo/hyperthermia)near drowning, hypo/hyperthermia)• 7. Severe burns7. Severe burns

Discharge will be based on the Discharge will be based on the following criteriafollowing criteria::

• 1. Stable haemodynamic parameters2. Stable respiratory status (patient extubated with stable arterial bloodgases) and airway patency3. Oxygen requirements not more than 60%4. Intravenous inotropic/ vasopressor support and vasodilators are nolonger necessary. Patients on low dose inotropic support may bedischarged earlier if ICU bed is required.

Discharge will be based on the Discharge will be based on the following criteriafollowing criteria::

5 .Cardiac dysrhythmias are controlled6 .Neurologic stability with control of seizures

7 .Patients who require chronic mechanical ventilation (eg motor neurondisease, cervical spine injuries) with any of the acute critical problemsreversed or resolved8. Patients with tracheostomies who no

longer require frequent suctioning