CHAPTER 44 Intensive Care Unit


The intensive care unit (ICU) consists of advanced medical technologies like modern ventilators, advanced hemodynamic monitoring systems, and skilled, trained personnel to support organ systems in critically ill patients.

As per definition, “critical care is defined as the direct delivery by a physician (s) of medical care for a critically ill or critically injured patient. A critical illness or injury acutely impairs one or more vital organ systems, such that there is a high probability of imminent or life-threatening deterioration in the patient’s condition.”

Admission to ICU (AS7.2)

The admission to intensive care is guided by the institutional policy that usually considers local population subtype (trauma, burns, medical) and their limitations like ICU size and expertise. The optimal resource utilization plus improving outcomes should be considered while admitting someone to ICU. The important considerations are as follows:

  • The specific patient needs like life-supportive therapies that can be only addressed in the ICU.

  • Available clinical expertise.

  • Diagnosis at the time of admission.

  • Unoccupied beds in ICU.

  • Objective health parameters at the time of referral.

  • Potential that patient will benefit from interventions.

  • Prognosis.

Patients requiring life-sustaining interventions, including cardiopulmonary resuscitation having a good prognosis, should be given priority over one with a significantly lower probability of recovery. The patients requiring mechanical ventilation or in sepsis should be admitted to ICU.

Patients should not be transferred to the general ward unless the ward is a high-dependency unit.

The following table is a summary of resource allocation and monitoring of patients receiving in-hospital care (Table 44.1).

Table 44.1 Framework to guide the level of intensive monitoring and care

Table 44.1 Framework to guide the level of intensive monitoring and care


Types of patients

Nurse-to-patient ratio


ICU (level 3)

Critically ill requiring hourly as well invasive hemodynamic monitoring

1:1 to ≤ 1:2

Advanced hemodynamic support, invasive mechanical ventilation, renal replacement therapy, ECMO

Intermediate medical unit (level 2)

Unstable patients requiring nursing interventions, laboratory workup or 4 hourly monitoring

≤ 1:3

Noninvasive ventilation, IV drug administration, antiarrhythmic drugs

Telemetry (level 1)

Stable patients but requiring frequent monitoring

≤ 1:4

IV drugs

Ward (level 0)

Stable patient not requiring testing as well as monitoring lesser than 4 hourly

≤ 1:5

IV antibiotics, radiology, and laboratory workup

Abbreviations: ECMO, extracorporeal membrane oxygenation; ICU, intensive care unit; IV, intravenous.

ICU Functioning (AS7.1)

The functioning of ICU depends upon the organization model followed by a given ICU. A given ICU can be open, closed, or semiclosed type as described below:

  • Open ICU: The specialty teams hold the admission right, and the intensivist acts as a consulting physician.

  • Closed ICU: The intensivist decides on admitting a patient, and the specialty team helps the intensivist.

  • Hybrid/transitional/semiclosed ICU: The intensivist and the specialty physician work in collaboration with equal distribution of decision-making power with regard to the patients.

The comparative summary of types of ICU is tabulated in Table 44.2.

Table 44.2 Types of ICU

Table 44.2 Types of ICU






The primary physician managing the case




More satisfaction to attendants





Presence leads to better resource utilization, better management

Physician conflict

Less likely

May be

More than closed

May lead to conflict on patient’s treatment decision





Shortage of trained intensivists


Less efficient

More efficient

More efficient

Evidence-based medicine leads to more efficiency of closed as well as hybrid ICU

Abbreviation: ICU, intensive care unit.

“We do not have ‘his or her’ patients, we have ‘our’ patients, and if the home team feels that there may be aspects of our treatment that require explanation, we are only too happy to discuss this with them—civilly.”

Explanation: The above quotation says that the intensivists and the treating physicians should treat each patient by a team approach and not by an individual approach. The treatment decisions and steps must be discussed and best one should be chosen in the part of patient’s welfare.

Monitoring in ICU (AS7.5)

The patients admitted to the ICU are critically ill, have multiple organ dysfunction, and hence require vigilant monitoring of each organ function with the timely institution of intervention to improve patient’s outcome.

According to the National Institute for Health and Care Excellence (NICE) guidelines, monitoring of heart rate, respiratory rate, blood pressure, and oxygen saturation is minimum in all intensive care patients. However, more advanced and invasive monitoring should be used for patients with a poor cardiorespiratory reserve and raised intracranial pressure.

The mnemonic “FAST HUGS BID“ is simple to use and apply in critically ill patients and guides an intensivist not to miss any aspect of patient care during ICU stay.

  • F-Feeding (to provide adequate calorie and protein).

  • A-Analgesia (pain relief in surgical patients OR during the painful procedure).

  • S-Sedation (to tolerate the discomfort of the endotracheal tube and other invasive lines/catheters).

  • T-Thromboprophylaxis (use of mechanical or pharmacological means to prevent deep vein thrombosis).

  • H-Head elevation (30-45 degree to prevent aspiration and ventilator-associated pneumonia).

  • U-Ulcer prophylaxis (use of antacid/proton pump inhibitor or H2 blockers to prevent stress ulcer of the gastrointestinal tract).

  • G-Glycemic control (tight control sugar helps to avoid infectious complications and improve survival, target <200 mg/dL).

  • S-Spontaneous breathing trial (to check for readiness for liberation from mechanical ventilation).

  • B-Bowel care (to ensure normal bowel movement with initial of early feeding and taking care of constipation).

  • I-Indwelling catheters (removal of invasive lines and catheters when these are no more required to prevent infectious and thrombotic complications).

  • D-Deescalation of antibiotics (stopping or switching of antibiotics to narrow-spectrum to decrease antibiotic resistance).

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Dec 11, 2022 | Posted by in ANESTHESIA | Comments Off on CHAPTER 44 Intensive Care Unit

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