Anaesthesiology
Intensive Care Management
Intensive care for MBBS and NEET-PG: ICU structure and admission criteria, the unconscious patient, ventilator setup, lung-protective ventilation and ICU monitoring, mapped to NMC codes AS7.
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Intensive Care Management
Intensive care for MBBS and NEET-PG: ICU structure and admission criteria, the unconscious patient, ventilator setup, lung-protective ventilation and ICU monitoring, mapped to NMC codes AS7.
This chapter covers the care of the critically ill patient in the intensive care unit, from its structure and admission criteria to the management of the unconscious patient and the ventilator. It sets out lung-protective ventilation, monitoring, sepsis and the daily care bundles that reduce complications.
High-yield: Intensive Care Management
- The intensive care unit provides organ support and continuous monitoring for critically ill patients who need more than a general ward can offer.
- Level 1 care is ward-based, level 2 is high dependency with single-organ support, and level 3 is intensive care with multi-organ or advanced respiratory support.
- The Glasgow Coma Scale grades eye, verbal and motor responses out of 15, and a score of 8 or less usually indicates a need to secure the airway.
- The unconscious patient is first assessed by airway, breathing and circulation, then a rapid search for reversible causes such as hypoglycaemia and opioid toxicity.
- Mechanical ventilation is set by tidal volume, respiratory rate, positive end-expiratory pressure and the inspired oxygen fraction.
- Lung-protective ventilation uses a low tidal volume of about 6 millilitres per kilogram of predicted body weight to limit ventilator-induced lung injury.
- Positive end-expiratory pressure keeps alveoli open, improves oxygenation and reduces the inspired oxygen requirement.
- The acute respiratory distress syndrome is defined by acute onset, bilateral infiltrates and hypoxaemia not fully explained by cardiac failure.
- Sepsis is a life-threatening organ dysfunction from a dysregulated host response to infection, and early antibiotics and fluids improve survival.
- Weaning from the ventilator uses a spontaneous breathing trial once the patient is awake, oxygenating well and haemodynamically stable.
- Continuous monitoring in intensive care includes electrocardiography, invasive arterial pressure, central venous pressure, oxygen saturation and urine output.
- Stress ulcer prophylaxis and venous thromboembolism prophylaxis are part of the routine daily care bundle for the ventilated patient.
- A ventilator-associated pneumonia bundle includes head-up positioning, oral care, sedation holds and daily assessment of readiness to extubate.
- Clear admission and discharge criteria ensure intensive care beds are used for patients most likely to benefit from organ support.
Ventilator essentials
- **Tidal volume:** About 6 mL/kg predicted body weight for lung protection.
- **PEEP:** Keeps alveoli open, improves oxygenation, lowers oxygen requirement.
- **GCS 8 or less:** Usually needs a secured airway to protect against aspiration.
- **Weaning:** Spontaneous breathing trial when awake, oxygenating well and stable.
NMC competencies in this chapter
- **AS7.1:** Structure and functions of the intensive care unit
- **AS7.2:** Criteria for ICU admission and discharge
- **AS7.3:** Management of the unconscious patient
- **AS7.4:** Principles and practice of ventilator setup
- **AS7.5:** Principles of ICU monitoring
Frequently Asked Questions
When does an unconscious patient need the airway secured?
A Glasgow Coma Scale score of 8 or less usually means the patient cannot protect the airway and needs intubation. Reversible causes such as hypoglycaemia and opioid toxicity should be excluded first.
What is lung-protective ventilation?
Ventilation using a low tidal volume of about 6 millilitres per kilogram of predicted body weight, with appropriate positive end-expiratory pressure, to limit ventilator-induced lung injury.
What does positive end-expiratory pressure do?
It keeps alveoli open at the end of expiration, improving oxygenation and allowing a lower inspired oxygen fraction, which reduces the risk of oxygen toxicity and atelectasis.
How is a patient weaned from the ventilator?
When the patient is awake, oxygenating well and haemodynamically stable, a spontaneous breathing trial is done. If it is tolerated with a stable pattern, the patient can be extubated.
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