ADMISSION CRITERIA TO THE INTENSIVE CARE UNIT د. ماجد عمر القطان إختصاصي طب طوارئ

The Intensive Care Unit is an expensive resource area and should be reserved for patients with reversible medical conditions with a reasonable prospect of substantial recovery

CLINICAL EXAMINATION OF THE CRITICALLY ILL PATIENT

Recognising the critically ill patient Cardiovascular signs Cardiac arrest Cardiac arrest Pulse rate 140 bpm Pulse rate 140 bpm Systolic blood pressure Systolic blood pressure (BP) <100 mmHg Tissue hypoxia Tissue hypoxia Poor peripheral perfusion Metabolic acidosis Hyperlactataemia Poor response to volume Poor response to volumeresuscitation Oliguria: <0.5 ml/kg/hr Oliguria: <0.5 ml/kg/hr (check urea, creatinine, K+)

Respiratory signs Threatened or obstructed airway Threatened or obstructed airway Stridor, intercostal recession Stridor, intercostal recession Respiratory arrest Respiratory arrest Respiratory rate 35/min Respiratory rate 35/min Respiratory ‘ distress ’ : use of Respiratory ‘ distress ’ : use of accessory muscles; unable to speak in complete sentences SpO2 < 90% on high-flow O2 SpO2 < 90% on high-flow O2 Rising PaCO2 > 8 kPa (> 60 mmHg), Rising PaCO2 > 8 kPa (> 60 mmHg), or > 2 kPa (> 15 mmHg) above ‘ normal ’ with acidosis

Neurological signs 1. Severe head trauma 2. Status epilepticus 3. Meningitis with altered mental status or respiratory compromise 4. Acutely altered sensorium with the potential for airway compromise 5. Progressive neuromuscular dysfunction requiring respiratory support and / or cardiovascular monitoring (myasthenia gravis, Gullain- Barre syndrome ) 6. Brain dead or potentially brain dead patients who are being aggressively managed while determining organ donation status

Indications for considering renal replacement therapy Oliguria (<0.5ml/kg/h) Oliguria (<0.5ml/kg/h) Life threatening hyperkalaemia (>6 mmol/l) resistant to drug treatment Life threatening hyperkalaemia (>6 mmol/l) resistant to drug treatment Rising plasma concentrations of urea or creatinine, or both Rising plasma concentrations of urea or creatinine, or both Severe metabolic acidosis Severe metabolic acidosis Symptoms related to uraemia (for example, pericarditis, encephalopathy) Symptoms related to uraemia (for example, pericarditis, encephalopathy)

Endocrine 1. Diabetic ketoacidosis complicated by haemodynamic instability, altered 1. Diabetic ketoacidosis complicated by haemodynamic instability, altered mental status mental status 2. Severe metabolic acidotic states 2. Severe metabolic acidotic states 3. Thyroid storm or myxedema coma with haemodynamic instability 3. Thyroid storm or myxedema coma with haemodynamic instability 4. Hyperosmolar state with coma and/or haemodynamic instability 4. Hyperosmolar state with coma and/or haemodynamic instability 5. Adrenal crises with haemodynamic instability 5. Adrenal crises with haemodynamic instability

Endocrine 6. Other severe electrolyte abnormalities, such as: 6. Other severe electrolyte abnormalities, such as: - Hypo or hyperkalemia with dysrhythmias or muscular weakness - Severe hypo or hypernatremia with seizures, altered mental status - Severe hypercalcemia with altered mental status, requiring haemodynamic monitoring haemodynamic monitoring

Gastrointestinal 1. Life threatening gastrointestinal bleeding 1. Life threatening gastrointestinal bleeding 2. Acute hepatic failure leading to coma, haemodynamic instability 2. Acute hepatic failure leading to coma, haemodynamic instability 3. Severe acute pancreatitis 3. Severe acute pancreatitis

Haematology 1. Severe coagulopathy and/or bleeding diasthesis 1. Severe coagulopathy and/or bleeding diasthesis 2. Severe anemia resulting in haemodynamic and/or respiratory 2. Severe anemia resulting in haemodynamic and/or respiratory compromise compromise 3. Severe complications of sickle cell crisis 3. Severe complications of sickle cell crisis 4. Haematological malignancies with multi-organ failure 4. Haematological malignancies with multi-organ failure

Multi-system 1. Severe sepsis or septic shock 1. Severe sepsis or septic shock 2. Multi-organ dysfunction syndrome 2. Multi-organ dysfunction syndrome 3. Polytrauma 3. Polytrauma 4. Dengue haemorrhagic fever/dengue shock syndrome 4. Dengue haemorrhagic fever/dengue shock syndrome 5. Drug overdose with potential acute decompensation of major organ 5. Drug overdose with potential acute decompensation of major organ systems systems 6. Environmental injuries (lightning, near drowning, hypo/hyperthermia) 6. Environmental injuries (lightning, near drowning, hypo/hyperthermia) 7. Severe burns 7. Severe burns

Discharge will be based on the following criteria: 1. Stable haemodynamic parameters 2. Stable respiratory status (patient extubated with stable arterial blood gases) and airway patency 3. Oxygen requirements not more than 60% 4. Intravenous inotropic/ vasopressor support and vasodilators are no longer necessary. Patients on low dose inotropic support may be discharged earlier if ICU bed is required.

Discharge will be based on the following criteria: 5. Cardiac dysrhythmias are controlled 6. Neurologic stability with control of seizures 7. Patients who require chronic mechanical ventilation (eg motor neuron disease, cervical spine injuries) with any of the acute critical problems reversed or resolved 8. Patients with tracheostomies who no longer require frequent suctioning