Systemic Approach In Intensive

Care Medicine
Badrul Amin
 Introduction

• Understand the thought process of the intensivist in

managing ICU patients.
• Conventional approach in medicine - history,PE ,DD,Ix
and Tx
• ICU patient is complex,multisystem disease processes
• Understand that the initial diagnosis for ICU admission is
often not the problem which keeps the patients in ICU
• Review patient
• List of problems by hierarchy
• Role - clinical problem solver

- management plan construction

But 1st, find the problem !

Patients with problems related to disease
•Cardiac arrest survival

•traumatic brain injury

•spinal cord injury

•obstetric

•intra abdominal catastrophe

 Principle of Management

•Admission - major physiological derangement - invasive monitoring / intensive interventions

•Derangements like ???

•Hemodynamic Insufficiency

•Respiratory Insufficiency

•Deteriorating consciousness level

•Fuid, Electrolyte imbalance + renal dysfunction

•Purpose of Intensive Care

•Reverse abnormal physiology

•Control source of problem

•Create favorable healing environment

 QUESTIONS TO ASK ?

•Why admitted ?

•What happened thereafter ? Complications ?

•What chronic health problems ?

•Why still admitted ? Currently what problem ?

•How are we addressing problem now ?

•Prognosis ? Futile situation ?

 History & Identification
Of Known Problems
•Purpose

get facts - set foundation - further physical examination, data intepretation

•Dealing with Elective / emergency surgery / medical

•Age, baseline health status

•Problems admitted with

•Complications that followed

•Problem keeping patient

•Physiologic targets
 Examination

•Ensure infection control procedures observed

•Physically examine from afar ; patient, environment, technology

•Step back - overall look - move in

•Walk up to bed ; isolation, equipment, odor

•End of bed ; comatose, pale, jaundice, head up

•1. Environment

•cubicle - bed type, isolated, infection cntrl

•Infusion - meds Insulin , fluids TPN

•Ventilator - setting, FiO2, Sp02, strategy

•Monitor - vitals, arrythmias, NIBP, WHY ???

•Equipment - Intravasc catheters

- renal replacement therapy
- special cooling bed / trauma bed
- Surgical drains
- ICP monitor
•2. System Based Approach - H2T . F2B

•Infection control, full exposure, modesty

•Approach, introduce, simple command

•Systematic - IPPA

•A . B . C. D . E . F. G

•List Problems b(active/inactive,health status,allergies,alcoholism)

•Specific Plan for each (specific & general), further Ix,

•Review ECG, RADIO, PATHO, REPORTS

•Communicate with patient, family, nurses about management, address concerns,

•Family meeting - discuss treatment options, progress

•F AST HUG maintenance

•ETHICS - AUTONOMY, BENEFICIENCE, NON MALEFICIENCE, JUSTICE

•A - irway ; ETT size, depth, cuff pressure, if tracheostomy; skin around
insertion

•B - reathing ; Observe, effort, rate, distress, examine lungs, chest drain,

ventilator - spont / controlled, Sp02, PEEP, sputum, CXR

•C - irculation ; Periphery pulses, heart, cardiovascular drugs, MAP,

rhythm, urinary output, acid base, lactate, ECG

•D - isability ; Simple tasks, assess GCS, C&P NS

•E - lectrolytes

•F - luids ; Fluid status, balance, management; tissue turgor, peripheral

edema, JVP, CVP, Examine intravascular devices - infection, thrombosis,

•G - astrointestinal ; abdomen, renal function, blood glucose, bowel

motion, peripheries - impaired perfusion, pressure areas, DVT, drains -
bottles, fluid types (blood, serous, pus), dressing, wound, puncture sites
•F - luid & Feces

•I - nfection

•D - rugs (medication ; dosage, action, duration, SE)

•D - ialysis

•L - ines (Indication, insertion days, complications)

•E - lectrolytes
 FAMILY MEETING

•Family members - rarely calm, rational.

•Stressed, nervous, aggressive sometimes

•Need
•Good structure,
•Objectives,
•Layman language
•Introduction - you, staff, relationships, Explain WHY meeting ?

•Gather information - ? they know & think of future. Best rep

•Give information - Explain Condition, Prognosis, Ix, Treatment

•Check understanding

•Agree to a plan - Clear conclusion, all agree

•Plan next meeting - If above unsuccessful, plan another

•Document - objectives, discussion, aggreement, attendance