The Intensive Care Medicine is a medical specialty that deals with diagnosis and therapy acutely life-threatening conditions and diseases is concerned. This usually happens in specially equipped wards of a hospital, the so-called intensive care units (also called intensive therapy unit (ITS), intensive care unit (IPS) or intensive care unit (ICU)). These are led by specially trained specialists such as anesthetists , internists , surgeons , pediatricians or neurologists and specially trained nurses ( health and specialist nurses for anesthesia and intensive care ). Due to the high level of care required, one nurse is only responsible for a few patients. The treatment of patients in the context of emergency medicine often bears the characteristics of intensive care medicine.
Intensive care medicine has its historical roots in anesthesiology , and the Danish anesthetist Björn Ibsen is generally considered to be the founding father of the first intensive care unit . In 1954 Ibsen the first intensive care unit in Copenhagen, as a direct result of the great polio - epidemic of 1952. The long-term ventilator patients was the reason that such elaborate methods and institutions were created. Another preliminary stage of today's intensive care units were the coronary care units (CCU). These were stations for ECG monitoring of heart attack patients with the option of defibrillation in the case of ventricular fibrillation or ventricular tachycardia . They were promoted by one of the inventors of defibrillation, the American Bernard Lown . The first German monograph on the subject of intensive therapy is the work on postoperative early complications published in 1956 by the surgeon Ernst Kern and the anesthetist Kurt Wiemers at Thieme Verlag .
Intensive care medicine is not an independent subject in Germany. Specialists in the fields of anesthesiology, surgery, internal medicine, pediatric and adolescent medicine, neurosurgery and neurology can use the additional qualification of intensive care medicine after 24 months of advanced training. In Austria, intensive care medicine is an additive subject to internal medicine. In Switzerland, on the other hand, there is its own specialist in intensive care medicine, which requires six years of advanced training.
In order to ensure good intensive care , after three years of training as a health and nurse , there is further training to become a specialist nurse for intensive care . This lasts two years part-time. In most cases, two years of professional experience, of which at least six months in the intensive care unit or anesthesia department, are required.
Spectrum of diseases
Intensive care units admit patients whose condition is threatening or whose condition could become threatening. Not only serious illnesses, but also conditions after extensive, long-lasting and highly invasive operations lead to intensive medical monitoring and, if necessary, treatment. In principle, a certain favorable prognosis of the pathological condition must be given.
The results of intensive care treatment vary widely depending on the underlying disease. The aim is to restore complete health or at least to achieve a largely autonomous state of the patient. So-called life-extending measures are therefore not an end in themselves.
The increase in process, structure and result quality in intensive care medicine is associated with a more extensive use of methods.
Terminal diseases, such as end-stage cancer , do not in themselves lead to admission to the intensive care unit, unless the patient's condition has deteriorated dramatically and admission is requested. In general, palliative medicine is established in this area .
Elementary disorders and complex clinical pictures
- Breathing disorders , e.g. B .:
- severe electrolyte imbalance
- Disorders of hemostasis (blood coagulation)
- Sepsis , SIRS
- Multiple organ failure , MOF, MODS
- acute kidney failure (up to 30% of intensive care patients are primarily or secondarily affected)
- Shock in the various forms: hemorrhagic shock , septic shock , hypovolemic shock , neurogenic shock, circulatory shock (cardiogenic shock), anaphylactic shock
- Postoperative conditions requiring monitoring (e.g. after heart surgery)
- severe heart disease ( myocardial infarction , decompensated heart failure )
- dangerous irregular heartbeat ( arrhythmias )
- Serious neurological diseases and disorders of consciousness: Stroke (treatment on special stroke units ), cerebral haemorrhage, subarachnoid haemorrhage , Guillain-Barré syndrome , severe meningitis, myastric crises, delirium, delirium tremens
- severe traumatic brain injury
- Multiple trauma and other life threatening injuries
- severe peritonitis
- acute pancreatitis
- severe poisoning
- severe general infections
The condition of the seriously ill can change rapidly. Standardized monitoring measures take this fact into account. The monitoring can be divided into methods with and without technical aids:
In any case, the prerequisite for adequate monitoring is personal observation by the nursing or medical staff, which is also due to an immense bed-side documentation requirement.
In order to assess the state of consciousness , there is usually still a lack of technical aids, so that neuromonitoring is carried out according to recognized and standardized verbal staging and condition classifications (e.g. Glasgow Coma Scale [GCS] for brain traumatized patients, which provides an index based on a verbal description of the patient's condition). For the assessment of pain are verbal rating scales (VRS) or visual analogue scales (VAS) were used.
In the intensive care unit, patients are also continuously monitored by staff using vital data monitors or patient monitors. In addition to continuous monitoring with alarm forwarding, the technical methods also allow more extensive standardization of the determination of measured values, since subjective errors are largely excluded. In addition, the vital signs monitors offer interfaces via which the measured values can be read out and automatically documented in a patient data management system.
A distinction is made between non-invasive and invasive methods when it comes to measuring methods. For invasive monitoring of a parameter, the body surface has to be penetrated in some way, for example in the form of catheters that are inserted into vessels of the body. This approach always involves a certain risk, be it through infection or causing bleeding. The strategic goal of technical development will always be the non-invasive determination of measured values.
Basic non-invasive monitoring methods deal with monitoring the cardiovascular and respiratory systems. Since the recording of the EKG , the monitoring of blood pressure , body temperature and the oxygen saturation of the blood are non-invasive methods, there are hardly any patients in an intensive care unit who do not have these measurements.
The invasive, mostly more comprehensive, but also more complicated procedures include arterial blood pressure measurement , measurement of central venous pressure , determination of the PiCCO and the use of the pulmonary artery catheter . With the latter method, parameters can be measured from which, for example, the oxygen depletion of the circulating blood and the pumping function of the heart with cardiac output can be determined. The procedure is relatively risky as it causes mechanical irritation to the heart, which can trigger cardiac arrhythmias. Lower-risk methods are currently being introduced that can replace the pulmonary catheter in certain indications.
Thanks to modern technical development, laboratory machines are increasingly finding their way into intensive care units. Frequently required values, such as blood gases , acid-base status, electrolytes, hemoglobin, can be determined on the bedside and thus quickly ( point-of-care testing ).
The methods are supplemented by imaging processes such as X-ray diagnostics (for example to assess the lungs) and ultrasound, which are usually carried out in the intensive care unit. Examinations such as CT or magnetic resonance are carried out in the special departments (X-ray department). For this purpose, the patients are transported to the respective large devices with mobile treatment units (e.g. ventilators) if necessary. Even in this mobile situation outside the ward, the quality of patient monitoring and care must not decrease.
The following are used in intensive treatment:
- Infusion , transfusion therapy
- continuous drug therapy using syringe pumps (e.g. catecholamines )
- Dialysis , hemofiltration
- artificial nutrition
- ECMO (extracorporeal membrane oxygenation)
Risk of infection
Patients in intensive care facilities have a five to ten times higher risk of infection compared to patients in normal wards (despite frequent controls of the germs present in the patient) . In the case of intensive care patients, various infection-promoting factors add up, which originate from the patient himself and from treatment measures.
On the patient side, the underlying disease and the accompanying diseases in particular lead to a weakening of the immune system. A poor nutritional status, old age (statistically speaking) and impaired consciousness also promote infection.
On the therapy side, a number of measures break through the natural immune barrier, so that complications can occur if the patient's organism is damaged:
- During ventilation, the damage to the self-cleaning mechanism of the tracheal and bronchial mucosa increases the risk of tracheo / bronchitis and pneumonia .
- The puncture point of central vascular access represents an entry point for infectious agents. This can lead to inflammation of the surrounding tissue and even sepsis .
- Access to body cavities: gastric tubes and urinary bladder catheters are also entry points for pathogenic germs.
- Special therapies: By increasing the gastric juice pH value as part of the so-called "stress ulcer prophylaxis", its disinfecting effect is canceled. This leads to the spread of germs into the gastrointestinal tract . The colonization by pathogenic germs can lead to functional impairment and failure of the intestine.
- Chemotherapy: The accompanying immunosuppression can result in sepsis .
Patients after bone marrow transplants are at high risk of infection due to the necessary immunosuppression.
The intensive care units also increasingly have to treat patients who are infected with germs that are resistant to the usual antibiotic treatments (for example oxacillin- or methicillin- resistant Staphylococcus aureus).
It is estimated that two thirds of all infections on the ward have been acquired ( nosocomial infection ). For these reasons, special hygiene measures are necessary in intensive care units in order to reduce the risk of infection:
- Structural measures: The stations are equipped with a lock system in which staff and visitors can change their clothes.
- Area clothing: The staff wear special clothing that is only worn inside the intensive care unit.
- Hand hygiene : The hands of the staff have been found to be the greatest reservoir of transmission. Therefore, hand disinfection is often necessary when working on the patient. Visitors must also disinfect their hands before entering the intensive care unit.
- When working with particularly immunocompromised patients, mouth and nose protection must be worn to avoid the transmission of pathogens that spread through droplet infection .
- Isolation : Patients with an extremely weakened immune system (bone marrow transplantation) must be isolated for their own protection. In contrast, patients with multi-resistant germs (MRSA, see above) are isolated to protect fellow patients. Many interdisciplinary intensive care units have special rooms for infected or colonized patients that have their own lock system.
Therapeutic measures should specifically support normal body functions, such as B. the promotion of oral or enteral feeding instead of parenteral nutrition .
Under the circumstances encountered in intensive care medicine, from a hygienic point of view, a constant balance must be made between necessary (often life-sustaining) measures and their side effects.
- Semmelweis-Reflex - In 1847/48 Semmelweis attributed varying degrees of puerperal fever to poor hygiene among doctors and hospital staff. His findings have been rejected or denied for almost two decades. - At that time, many doctors could not imagine that they could pose a risk to the patient.
- Pediatric Critical Care Medicine
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- German Society for Anaesthesiology and Intensive Care Medicine V.
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