MONITORING OF CRITICALLY ILL PATIENT

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An Intensive Care Unit (ICU) is fully equipped with monitoring and technical facilities and patient can receive continuous expert nursing care and the constant attention of appropriately trained medical staffs. management of these patients in general wards becomes difficult. the history is often incomplete. which is not possible in general wards. So. .Introduction In a critically ill patient. reverse or minimize damage to vital organs. physical examinations are frequently inconclusive and the signs on which the clinical diagnosis depend often disappear when the patient approaches death making the diagnosis difficult to establish. To prevent. Objectives while managing these patients:   To sustain life.

4. 8. Hematocrit. . 6. The most frequently used scoring system is APACHE II (Acute Physiology Assessment and Chronic Health Evaluation). 5.core Mean arterial pressure Heart rate Respiratory rate. White blood cell count. The physiological parameters are: 1.Whom to label as Critically Ill? The identification of the at risk patient or those patient who could benefit from intensive care treatment is largely based on scoring systems. 3. Glasgow coma score. Temperature . 12. 9. 2. 11. Oxygenation Arterial pH Serum sodium Serum potassium Serum creatinine 10. which is based on evaluation of 12 physiological variables which are altered in response to stress or disease process. 7.

No single parameter is significant. Blood pressure: May be monitored intermittently with sphygmomanometer. Continuous monitoring with line placed in radial artery is preferable.   ECG: Gives information about rate and rhythm changes.Monitoring of critically ill Monitoring of physiological responses to stress or disease not only allows the assessment of the physiological reserve of the patient but will also give a baseline against which the effectiveness of any applied treatment can be judged. Modified form – lead CM5 can be used to detect both ischaemic changes and arrhythmias.   . Monitoring of Cardiovascular System: 1. but is not useful to monitor ischaemic changes. Changing parameters of trends are more significant. 2.

Useful means of assessing the circulating volume and determining the appropriate rate of intravenous fluid replacement. Measures the left ventricular end diastolic pressure. Pulmonary Artery Occlusion Pressure (PAOP): More beneficial than CVP in critically ill patient.   Central Venous Pressure (CVP): Monitored by placing a catheter in either subclavian or internal jugular vein. Cold 5% Dextrose is injected in central vein and after admixture with total venous return in right ventricle.   6. temperature of blood is measured in pulmonary artery with a thermistor. Fluid balance: By maintaining strict input/output chart 4.  . Cardiac Output: Most commonly measured by thermodilution technique.   5.3. right ventricular dysfunction and pulmonary vascular disease.

Monitoring of CVP Gastric tonometry .

 9. PCO2 of gastric content is estimated using a silicon balloon attached to the tip of nasogastic tube.    o o  . (Since PCO2 of luminal content is thought to equilibriate with gastric mucosal intracellular PCO2). Impaired oxygen utilization by these cells. 8. May be the earliest index of impaired core tissue perfusion with oliguria and arterial acidaemia developing later on.7. Haematocrit and Haemoglobin concentration: Hct of 35% and Hb% of 12-14 gm/dl is thought to be optimal because reduction of viscosity of blood is thought to enhance tissue perfusion. Gastric tonometry: Indirect means to measure gastric mucosal intracellular pH.  Temperature: Gradient between core and peripheral temperature is a better indicator of peripheral perfusion. Localised intracellular acidosis may be due to: Decreased oxygen supply to these cells.

Cannot differentiate Carboxyhaemoglobin form Oxyhaemoglobin. . Not effective when peripheral perfusion is reduced. Normal >97%. Arterial blood gas analysis: Especially beneficial in ventilated patient.Monitoring of Respiratory System: 1. Helps to adjust inspired oxygen and minute volume to achieve a desired PaO2 an PaCO2 respectively.      2. Spectrophotometric analysis.    Oxygen saturation by Pulse Oximetry: Probe is attached to finger or ear lobule. Also useful to monitor acid-base balance.

Made by placing a device within a cranial vault by making a small burr hole in parietal or frontal areas of non dominant hemisphere. Indicated in patients with head injury.    2. Urinary flow: Sensitive measure of renal perfusion. Should not fall below 0. brain tumours and encephalitis. Measured by simply placing a self retaining catheter. Serum Electrolytes. ü ü Intracranial pressure (ICP): Normal <10mm of Hg.Monitoring of Renal System: 1. subarachnoid haemorrhage. ICP above 20-25 mm of Hg warrants immediate correction. Cerebral oedema and haemorrhage causes a rapid rise in ICP. hepatic encephalopathy. ü ü ü . Urea and Creatinine Monitoring of Central Nervous System: 1.5ml/kg body weight/hour.

  Cerebral function monitor (CFM): Compact form or EEG where unwanted frequencies are filtered. Indicated during carotid artery surgery and those who are likely to develop convulsions. Conclusion: Different patients respond to a similar insult in different ways and have different physiological reserves. Assessment of physiological status is important in allowing these differences to be appreciated. Monitoring of Haematological parameters: 1.   Assessment of Clotting function: For those who develop haemostatic failure and acquired coagulopathies. In addition. Fibrin Degradation Products (FDP) or D-dimer. . which is the main aim of meticulous monitoring of these paitents.2. many of the treatment options we use in the critically ill patient require some form of physiological monitoring for us to gauge their effectiveness. Prothrombin time. Activated Partial Thromboplastin Time (APTT).

uk/journal/vol44_6/446 0010.htm . 2. Clinical Medicine by Parveen Kumar & Michael Clark – 3rd Edition. Davidson’s Principles and Practice of Medicine – 18th Edition.ac.References: 1. 3.rcsed. Website http://www.