Care in the ICU

Alarms

Alarms are common in the ICU. All team members are paying attention to the alarms. If something requires immediate attention, a nurse or another staff member will come to the bedside right away. Alarms of life-threatening problems will sound different, and many people in the unit will rush to help. Unfortunately, alarms are only a “heads-up” to the team. In fact, 4 out of 5 alarms do not indicate a real problem because they may be due to false readings, patients moving around, or just an indication that something needs to be done later, such as a medication pump that will soon finish.

Pain Management in the ICU

Patients may experience pain and discomfort while in the intensive care unit (ICU).

• Preventing and relieving pain are top priorities of the health-care team.
• Because of your personal knowledge of the patient, you may be better able to recognize facial expressions and behaviours that indicate pain. If you think your loved one is in pain, please discuss this with the nurse.

Many patients in the ICU are unable to talk, point, or nod their head for some part of their ICU stay. For these patients, nurses use a tool such as facial expressions and other behaviours that indicate pain. If pain is present, pain-relieving medications will be given. Some medications may make the patient sleepy; other strategies to relieve pain include positioning and massage.

Acute Pain Service: Sometimes it can be difficult to completely relieve pain. The team may try different combinations of drugs to be successful. A specialist pain team can provide additional advice to the ICU team.

How does my loved one get food and nutrition at the ICU?

If the patient is awake, alert, and able to safely swallow, he or she can eat regular food. Some patients may be given a variety of supplements or a specialized diet to make sure that they get enough nourishment. It’s safe, for most patients, to receive no nutrition for up to 7 days.

Patients who cannot eat adequately or safely may require specialized nutrition therapies, for example:

• Tube feeding (enteral nutrition) is liquid nutrition fed directly into the stomach or the small bowel using a tube (Link to NG tube.). This is the preferred method of providing nutrition for patients who cannot eat.
• IV nutrition (parenteral nutrition) is provided directly into the bloodstream. This method is used for patients who cannot tolerate tube feeding.

Preventing and treating infections

Infections are a common reason for patients to be admitted to an intensive care unit. But, unfortunately, patients can also pick-up new infections while they are in the ICU.

The most common ICU infections include:

• Ventilator-associated pneumonia (related to being on a mechanical ventilator for breathing support);
• Central line-associated bloodstream infection (related to the intravenous lines);
• Catheter-associated urinary tract infections (related to the urinary or Foley catheters);
• Surgical site infections (related to surgeries undergone before or during ICU stay);
• Clostridium difficile infection (a bowel infection that can happen after antibiotic use).

Antimicrobial Stewardship Team (AST): A team made up of dedicated Infectious Diseases (ID) physician consultants and ID pharmacists working towards improving the appropriateness of antibiotic usage within the hospital.

The ICU and hospital teams work hard at implementing best practices to reduce the number of infections. Some of these precautions start as soon as a new patient enters the ICU:

• Upon arriving in the ICU, a bacterial screening swab is taken for testing to determine if the patient is already carrying any antibiotic-resistant bugs;
• Patients carrying antibiotic-resistant bug are separated from the other patients to prevent spreading;
• Patients are also isolated if they are suspected of having a possible viral respiratory infection, or a vomiting and diarrheal illness.

The teams also use other measures to keep infections in check. You might have noticed some of these approaches in the ICU, such as:

• Keeping the head of the bed raised above 30 degrees to lower the risk of ventilator associated pneumonia;
• Special sterile techniques to insert intravenous lines to prevent line-associated infections;
• Avoiding overuse of antibiotics to lower the risk of Clostridium difficile and reduce the emergence of new antibiotic resistant bugs.

The Risk of Blood Clots

Venous Thromboembolism (VTE) is a term used to describe abnormal blood clots in the body.

Normally, blood flows easily through the veins. If the blood flow slows down, a blood clot can form and acts like a plug in the vein.

These blood clots include:

• Deep Vein Thrombosis (DVT) is a blood clot in the deep vein of the leg. DVT can cause pain and swelling of the leg. It can also damage the vein;
• Pulmonary Embolism (PE) is a blood clot that travels to the lungs. PE can cause difficulty with oxygenation of the blood, and if severe enough or untreated, can lead to death.

Some pre-existing conditions can increase the risk of developing Venous Thromboembolism. Other factors can further increase the risk of clots. These include:

• Major trauma;
• Injuries to the leg;
• Recent surgery;
• Acute illness;
• Reduced movement while in the hospital.

To lower the risk of blood clots patients are given daily injections of an anticoagulant medication that makes the blood less likely to form clots that cause Venous Thromboembolism. Other methods to prevent blood clots include Thromboembolic Deterrent (TED) stockings or compression stockings, which provide light compression to promote proper circulation of the blood.

Predicting what might happen to the patient

Being in the ICU can be like a roller coaster ride for patients and families. One day, things are getting better, the next day, everything may seem worse again. This can be very difficult emotionally. Families will frequently ask the team about the patient’s prognosis and whether their loved one will survive. While there is a lot of uncertainty in the ICU, the team can speak to you in general terms about what happens to most patients with certain conditions.

ICU research team

The research team helps with clinical and academic research studies that could lead to better medical treatments and improve the quality of care.

There are different types of studies that take place in the ICU. They can involve:

• Observing patient’s care with the usual treatment and comparing it with a study treatment;
• Offering a new medication or medical intervention;
• Conducting observations, questionnaires and interviews with the clinical staff, the patients and family members.

All studies that take place in the ICU at Sunnybrook completed a review by the Sunnybrook Research Ethics Board, which supervises the ethical conduct of research at the hospital.

• All patients in the ICU can be considered for participation in any of the research studies taking place at the time of their hospitalization. The staff intensivist responsible for your loved one’s care will be consulted before the research team presents the research options to you or the patient.
• Participation in research is voluntary. Patients and family members have the right to not be involved in a study. They can also withdraw from the study at any time without affecting the standard of care they receive at Sunnybrook.
• The best way to learn more about research eligibility or the current studies taking place in the ICU is to contact Critical Care Research at 416-480-6100 ext. 1719.