WHAT IS THE PURPOSE OF AN INTENSIVE CARE UNIT?

Intensive care units (ICU) are places in the hospital where the most seriously ill patients are cared for by specially trained staff. The staff consists of doctors, nurses, respiratory therapists, nutritionists, physical therapists, pharmacists, case workers and clergy. They work closely together as a team to provide the best possible humane care. Two things that make care in the ICU different than in a regular hospital care area are the nursing support and the special type of equipment in use. The level of nursing care in the ICU is higher than care in other parts of the hospital. ICU nurses are specially trained to care for the most ill patients. There are more nurses for patients than on regular hospital wards. The second thing that distinguishes an ICU is the use of advanced technology. The ICU team uses a number of specialized machines and devices, called monitors, to frequently check the heartbeat, blood pressure and breathing. There are machines that help patients breathe called mechanical ventilators. While it can be overwhelming to see so many machines, wires and tubes, each does its job to help the patient. There are many diseases and injuries that can lead to critical illness. Examples of problems that may require the special and expensive care in an ICU include:

1. Problems with the heart and blood vessels - such as very high blood pressure, very low blood
pressure (called shock), abnormal heart beats, or a heart attack. 2. Problems with the lungs - such as asthma, severe pneumonia, or pulmonary embolism (blood clots in the lung). Difficulty with breathing that is so severe that the patient may need a machine to help or take over breathing until the problem is corrected. 3. Problems with salts, chemicals, or minerals in the bloodstream - The body's cells require a number of substances that must be present in the correct balance for the body to work properly. Levels of substances such as sodium (salt), potassium and glucose (sugar) must be kept within a very narrow range. A level that is too high or too low can threaten life, and immediate treatment may be necessary. 4. Brain injuries - Severe brain injuries including bleeding, stroke and head trauma, may cause loss of consciousness, also called coma. Patients who are in a coma or who are at a high risk of coma are often watched and treated in the ICU until their condition becomes stable. 5. Severe trauma - such as auto accidents, gunshot wounds and burns. These patients may have multiple injuries that require specialized treatment and monitoring. 6. Major surgery - Patients undergoing major surgery, who need special monitoring or who are at high risk of having problems after the operation. They may have other serious health problems that can complicate care after surgery. To the casual observer, the ICU would seem a good place for patients to stay all the time they are in hospital because of the high level of care. This is not the case, however, for the following reasons: 1. Risks - ICU care involves a number of risks, especially of getting new infections. Since severe infections are common in critically ill patients, the longer a patient stays in an ICU, the greater is the risk of picking up an infection from other patients. Also, the bacteria causing these infections sometimes do not respond to antibiotics as well (these bacteria are called resistant strains). 2. Expense - It is very expensive to provide constant nursing attention for patients who are getting better. Most ICUs have rules for deciding which patients need this special form of care and when they can be transferred to another hospital ward. This change is part of recovery.

EXPECTATIONS
Families should understand a simple fact: modern medicine has produced many amazing breakthroughs in the past 20-30 years, but there are many diseases that cannot be treated. Patients are treated in the ICU because they are at risk of dying without such care. Many people mistakenly believe that physicians, by using the most modern machines, are able to reverse the dying process. There are always patients who cannot be saved even by the most advanced care that is available. Doctors may be able to offer a rough idea of a patient's chance of surviving, but with much less than 100% accuracy. We stress that Medicine doesn't have all the answers. Also, the dedicated health care team providing this art and science are only human and as such are imperfect beings. Critically ill patients and their families will have expectations of the health care workers. The following are among reasonable expectations:

1.

To Be Informed - It is reasonable to get the doctor's assessment of the problems which caused the need for care in the ICU. It is important to understand that it is not always possible to know the cause for an illness or why a disease worsens. Medical knowledge is incomplete despite new advances. Also, it often takes hours or days to get test results and to fit all the information together to make a diagnosis. You should expect to be told about major changes in your condition. You may ask about the assessment and treatment plan.

2.

To Speak with the Doctors - It is reasonable to have a chance to speak with the doctor on a regular basis. You should expect daily, or even more often, updates if you are very sick. While many doctors are involved, one primary attending doctor is always in charge and organizes the care plan. 3. To Decide Whether Procedures Should be Performed - When you go into the hospital, you usually sign a paper, called a consent form, which allows doctors and hospital staff to give basic treatments (for example intravenous tubes, called catheters, placed into the veins of the body, blood draws, and administration of medicines). Critically ill patients may need certain procedures that require additional permissions. These procedures may be tests to help figure out what is wrong or treatments to relieve symptoms or resolve problems. To help you decide if you want a procedure, you should be told (or "informed") of the benefits and common risks. This process is called "informed consent." All procedures have risks and the doctor performing the procedure can review the common risks. The benefits are what good is expected to come from the procedure. This information may be provided by word of mouth, but is best to also have it in writing. Occasionally, life-saving procedures are performed in an emergency when delay would harm the patient and there is not enough time to contact family members for consent. 4. To Ask for Second Opinions - In some hospitals, an ICU doctor who is "on-call" takes care of patients in the unit. In other ICUs, patients are cared for by their primary (family) doctor with the help of specialists. Occasionally, patients and the families may feel more comfortable if they can get a "second opinion." Most doctors will not be insulted if a patient or family member asks politely for another doctor to give a second opinion. Sometimes, it is possible to have doctors and other health workers meet with the family in a group - what we call a "family meeting." Family meetings can be held at the bedside of the patient, when the patient is able to help in decision-making. A family meeting is a chance for family members to ask questions and discuss care with doctors and nurses. Such a meeting helps to ensure that everyone has a common understanding of the problems and current plan. The meeting may help family members make decisions about care, especially when the patient is too sick to make decisions. Patients and families also have the obligation to conduct themselves in a courteous manner that is not disruptive to the ICU and the care of other critically ill patients.

CARDIOVASCULAR SYSTEM
The Cardiovascular System is the heart and all of the vessels that carry blood to the body. Blood carries oxygen and food that every cell in the body needs for life. If the heart or blood vessels fail to get enough blood to the body, the important organs of the body may be temporarily or permanently damaged. Myocardial infarction - or "heart attack" - happens when the heart muscle itself doesn't get enough blood because one or more of its blood vessels, called coronary arteries, becomes blocked (this used to be called "hardening of the arteries"). When this happens, an awake person may have chest pain or pressure, pain in the jaw, neck or shoulder, shortness of breath, sweating, nausea or vomiting. Critically ill patients are often not awake and so they may not be able to complain of these symptoms. Heart attacks are treated by measures to get blood flowing back through the blocked coronary arteries, but the longer the blockage is there, the more likely that heart cells will die leading to permanent damage. Treatments include medicines that thin the blood (like aspirin or heparin) or break down the clots (like a medicine called "TPA"), reduce the work of the heart (like nitroglycerin and medicines called "betablockers" or "ACE-inhibitors"). Often medicines are not enough and doctors must do a procedure called an "angiogram" in which a catheter is placed into the leg or arm and pushed up into the heart, and dye is given to show where the blockage is. Doctors may then be able to open the blockage with a balloon (called "angioplasty") or with a tiny hollow pipe (called a "stent"). However, in some cases, the blockage cannot be opened up at the time of an angiogram. Surgery may be needed in which blood vessels are removed from one part of the body (often the leg) and used to carry blood to skip over, or "bypass," the blockage. This is called "bypass surgery" or "CABG" (pronounced "cabbage" short for coronary artery bypass graft). Shock - is a term used to describe when the blood pressure drops to a dangerously low level. If the pressure falls enough, the cells in the body don't get enough oxygen and begin to die. If enough cells die, organs of the body, like the kidneys, brain and liver, may also stop working right. Common reasons for shock are severe infections (this is called "septic shock"), heart attacks (this is called "cardiogenic shock") or severe blood loss (called "hemorrhagic shock"). There are also other less common causes. In each situation, treatment of shock involves fixing the cause. In the case of septic shock, the infection must be found and treated with antibiotics. In the case of shock due to heart problems, the heart attack must be treated (see discussion of "Myocardial Infarction"). Sometimes shock cannot be treated and in other cases, if it has gone on for some time, the organs of the body have been damaged too much for the patient to survive.

Arrhythmia - is a term used to describe when the heartbeat, which normally goes at a regular rate of 60 to 100 beats every minute, becomes too fast or too slow. Sometimes medicines can be given to help. But other times, abnormal heartbeats are so bad that not enough blood gets to the organs of the body or blood backs up into the lungs. If this happens an electrical shock, given by two paddles on the chest wall, may be needed to put the heart back to a more normal rate. However, shocks are not successful in all cases and in some cases, the heart can even stop after a shock, in which case cardiopulmonary resuscitation (CPR) may be needed (see Information Sheet on Cardiopulmonary Resuscitation). Congestive Heart Failure - is a term used to describe when the heart fails to pump enough blood forward to the body and as a result, fluid builds up in the lungs, called "pulmonary edema." This can cause shortness of breath, sometimes so bad that a patient may need to go on a breathing machine until it can be treated (see Information Sheet on Mechanical Ventilators). Congestive heart failure can usually be treated with medicines like nitroglycerin and diuretics, which help the kidneys to get rid of excess fluids. But sometimes, other, stronger medicines are needed and in some cases the heart works so poorly that nothing short of getting a heart transplant can help the patient to feel better.

PULMONARY SYSTEM
The Pulmonary System includes the lungs and the muscles of breathing, such as the diaphragm, which pump air into and out of the lungs. The purpose of the lungs is to get enough oxygen into the body and to get rid of carbon dioxide that is a waste product of the body. Respiratory failure - Respiratory failure happens when a machine is needed to help with breathing. Respiratory failure may happen if not enough oxygen is getting into the blood. The most common reasons for this are pneumonia (lung infection, see below), heart failure (called "pulmonary edema") and inflammation of the lungs (sometimes called ARDS that stands for "acute respiratory distress syndrome"). Respiratory failure may also happen if the lungs fail to get rid of carbon dioxide. You can think of the lung muscles, such as the diaphragms, as a pump that gets air into the body and carbon dioxide out of the body. If the lung muscles tire out, carbon dioxide can build up in the body and a breathing machine (see Information Sheet on Mechanical Ventilators) may be needed to get rid of it while the muscles rest. Some common reasons for this type of failure include asthma and other obstructive lung diseases such as emphysema. Breathing machines don't fix the reasons for respiratory failure and there are many risks of staying on a machine. Doctors and hospital staff try to understand the reasons for respiratory failure, treat the causes as fast as possible and then try to get the patient off the breathing machine. This is reviewed in the Information Sheet on Weaning from Mechanical Ventilation. Pneumonia - is an infection of the lungs and a very common cause of critical illness. It happens when a germ, such as a bacteria or virus, enters the body, usually through the nose or mouth, and then goes down into the lungs causing them to flood with pus and fluid. Pneumonia can be a problem that leads to the need for hospitalization or it can occur as a complication in the hospital. Pneumonia often causes fever, cough and shortness of breath. Most pneumonias can be treated with drugs called antibiotics. Some pneumonias can be so serious that they stop enough oxygen from getting into the body, and the patient must be admitted to the hospital. If the pneumonia is very serious, a machine may be needed to help the patient to breathe until antibiotics and the patient's body fight off the infection (see Information Sheet on Mechanical Ventilators). When a patient has respiratory failure (see explanation above) and has a tube in the lungs connected to a breathing machine, there is a risk of germs entering the lungs through the tube. These types of pneumonias can make patients very sick because the germs in the hospital are often more difficult to treat than those outside the hospital (see section on Multiple Drug Resistant infections). Pulmonary embolus - Many patients who are admitted to the hospital don't get up and walk around every day because they are so sick. As a result of staying in bed, sometimes blood clots can form in the legs and pieces can break off and move to the lungs where they cause shortness of breath and chest pains. This is called pulmonary embolus. Very serious pulmonary embolus can cause respiratory failure (see explanation above) or even death. Blood thinners (medicines like heparin and coumadin) are used to treat pulmonary embolus and may be used to prevent blood clots of patients who are at risk.

KIDNEYS
The purpose of the kidneys is to remove waste from the blood which is carried out of the body in the urine when we pass water.

Kidney failure - A number of problems can cause the kidneys to be damaged and fail to remove waste from the body. Dehydration, low blood pressure, inflammation of the kidneys, effects of medicines or x-ray tests and blockage of the tubes that take urine out of the body are common reasons for the kidneys to fail. Patients with problems like high blood pressure or diabetes that have already damaged the kidney have a greater risk of getting kidney failure for one of the reasons listed above. When the kidneys cannot remove all of the wastes from the blood, waste builds up and can cause problems. Hemodialysis is used to remove wastes of the body that are normally removed by the kidneys (see Information Sheet on Hemodialysis).

GASTROINTESTINAL SYSTEM
The Gastrointestinal System is the mouth, gullet (or esophagus), stomach and intestines, that carry food into our body. Bleeding - A very common reason for admission to intensive care is bleeding from the esophagus, stomach or intestines. Ulcers in the stomach or intestines may cause belly pain, nausea and vomiting of blood. Tar-black stool is another sign of bleeding from the stomach or small intestines, called "upper GI bleeding." Tumors, outpouchings (called diverticuli), and blood vessel abnormalities in the lower intestines can cause bleeding from the colon or rectum called "lower GI bleeding." Endoscopy is a common procedure used to find the source of and sometimes even stop the bleeding (see Information Sheet on Gastrointestinal Endoscopy). Malnutrition - is a common complication of critical illness. Good nutrition is very important for the body's ability to heal and fight off infections. Food can be given by mouth, through a feeding tube (when a patient is unable to eat by mouth, see Information Sheet on Feeding Tubes) or by vein (when the gut is not working to take in food).

NERVOUS SYSTEM
The Nervous System is the brain, which is responsible for thinking and controlling other parts of the body, and spinal cord and nerves that connect the brain to the arms, legs and other organs. Stroke - is when a blood vessel of the brain becomes blocked, so that blood cannot carry oxygen to the cells beyond the blockage. If the blockage clears before permanent damage has occurred it is sometimes called a "mini-stroke" (or transient ischemic attack; "TIA" for short). If the blockage stays for long enough, brain cells begin to die, leading to permanent damage. Depending upon which cells in the brain die, patients may have difficulty moving arms or legs, talking or may even go into a coma. If a stroke is treated within a few hours and there is no bleeding into the brain, "clot-busting" drugs, like "TPA," can be used to dissolve the blockage. However, more often patients don't get to the hospital in time and once the cells have died, there is nothing that can bring the dead brain cells back to life. Aspirin and blood thinners may help to prevent more strokes, but can't bring back the brain cells that have already died. With time, some functions may return, but often patients with strokes have permanent disabilities. Encephalopathy - is a term used to describe when patients aren't thinking clearly or are confused. An infection or other illness that directly involves the brain may cause encephalopathy. Many illnesses that cause critical illness can cause encephalopathy without directly involving the brain. Encephalopathy is quite common, especially in older patients who get critically ill for any reason. In addition, medicines used to help the patient may also cause encephalopathy.

INFECTIONS
Infections are caused by germs: viruses, bacteria and fungus. The most common infections that require either coming into the hospital in the first place, or that occur as a complication of being in the hospital, are caused by bacteria. Sepsis - is the response of the body against a germ, and can occur from an infection in any part of the body. Weakness and ache are common symptoms of sepsis. Fever, a fast heart-beat and fast breathing are common signs of sepsis. The body's immune system tries to fight the infection, but with some infections, antibiotics are needed to help the body defend itself. If the infection gets worse it can involve the kidneys, brain, lungs and other organs of the body (see section on Multiple Organ Failure). And at its worst, some infections can affect the heart and blood vessels of the body, causing the blood pressure to fall. This is called septic shock and is very serious; it is one of the most common causes of death of patients who come into ICUs.

Ventilator-associated pneumonia - is a complication of being on a breathing machine (see Information Sheet on Mechanical Ventilators). Since being on a breathing machine often means having a tube in the lungs, germs from outside the body can move down through the tube into the lungs causing an infection called pneumonia. Since the germs are coming from the hospital, this can be very serious because the germs present in the hospital are often more difficult to treat than germs you catch at home. As a general rule, the longer a patient is on a breathing machine, the longer there is a risk of getting a ventilatorassociated pneumonia. Catheter-related infections - happen when germs from outside the body enter through a thin hollow tube, called a catheter, that is put into the body. The germs can enter a catheter that is in a blood vessel of the body used to give fluids and medicines or to measure pressure. Or the germs can enter a catheter that is in the bladder opening to drain urine, which can lead to an infection of the bladder or kidneys. Multiple-drug-resistant infections - are infections with germs that are not killed by the normal antibiotics. These germs can come from inside or outside the hospital, causing lung, catheter and other infections. These germs have been mentioned a lot recently in the news because they are an increasing reason for serious complications, especially for patients who are in an ICU.

MULTIPLE SYSTEM ORGAN FAILURE

Multiple System Organ Failure is when more than one organ of the body stops working normally. Since each organ of the body has its own important purpose to keep us well, the more organs that don't work properly, the less likely it is that a patient will get better from a critical illness. Organs can stop working, or "fail," for a number of different reasons. Some common reasons that cause more than one organ at a time to fail are serious infections, low blood pressure (called "shock") and serious injuries (called "trauma"). In general, the chance of a patient dying in the hospital increases each day that organs don't improve functioning. So, for example, patients with 3 failed organs for more than 3 days are very unlikely to survive.