Introduction to Critical
Care
Module 9
What is critical care nursing?
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Life threatening
Unstable
Complex
Specialised nursing
Intensive care
Critical to success.
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The place of efficient and effective critical
care services within the acute hospital.
Audit Commission. 1999. London.
Comprehensive Critical Care
Recommendations for modernising
critical care. DoH 2000.
Local management
 Levels of care
 Data management
 Follow up
 Outreach
 Early warning
 Staffing
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Supporting evidence
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Sub-optimal care.
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Predicting/preventing cardiac arrest.
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Brennan et al, 1991,
Ward admissions to ICU mortality
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Brennan et al, 1991, Leape et al, 1991. Wilson et al, 1995.
Late ICU referral > worse outcome.
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Schein et al, 1990.
Preventable in hospital deaths
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McQuillan et al, 1998.
Goldhill et al, 1999,
mortality after discharge from ICU.
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Rowan et al, 1993.
Levels of care
(Department of Health, 2000. Intensive
Care Society, 2002)
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Level 0
Needs can be met through normal ward care.
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Level 1
At risk of deterioration or recently relocated from higher levels of
care.
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Level 2
More detailed observation or intervention, including single organ
failure, and those stepping down from higher levels of care.
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Level 3
All complex patients requiring advanced respiratory support, or
support for multi organ failure.
Levels of care
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Mr A. had a hernia repair 2 days ago, awaiting
discharge.
Mrs. B took 20 paracetamol 24 hours ago, had
gastric washout and charcoal. Awake but
disinterested.
Levels of care
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Miss C. underwent emergency over sewing of a
gastric ulcer 2 days ago. Now has a chest
infection.
Mrs. C collapsed in the street following a cardiac
arrest today. CPR given at scene. Inotropic
drugs infused
Levels of care
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Mr. D suffered exacerbation of chronic
obstructive pulmonary disease. Ventilated and
sedated. Oxygen requirement = 6 (60%0.
Dr E underwent emergency abdominal surgery
24 hours ago (Aortic aneurysm rupture). In ICU.
Has 4 (40%) oxygen via mask, epidural for pain
relief, CVP line.
What do we do at the bedside?
AWARENESS
CLINICAL JUDGEMENT
TREATMENT
Bedside
AWARENESS
Observations
and vigilance
Bedside
Observations
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Respiratory rate
Heart rate
Blood pressure
Conscious level
Urine output
Respiratory rate
 Commonest physiological
abnormality of patients admitted
to ICU. Goldhill et al, 1999.
 Preceding arrest, change in
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Schein et al, 1990.
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Temperature
SpO2
Behaviour 84%
Respiratory function 53%
Mental function 42%
Mortality increases with the
number of abnormal physiological
values
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Bedside
1
2
3
4.4%
9.2%
23.4%
KNOWLEDGE
•Education
•Experience
•Guidelines
•Policies
•Procedures
•Resources
•MEWS
Bedside
TREATMENT
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Simple measures
A,B,C,
Oxygen
Fluids
Getting help
Bedside
Team work and
communication
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Sharing knowledge
and skills
Knowing your limits
Listening to others
Helping each other
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Communicating well
Good record keeping
Keeping the patient
and their family
informed
Case study 1
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42 year old man
Anterior resection for Ca rectum
6 days later faecal peritonitis
Laparotomy and admit to ICU overnight
Transferred back to the ward at 07:00
Case study 1
Leaving ICU
 T 36.2, RR 16, HR 97 (SR), BP 100/62,
CVP 0,
 NS 120, UO 80-90, NG/drains 1L
(1400)
 3l O2 via NS, SaO2 99%
A. C. T!
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High flow oxygen
Fluids
Get help.
Referred by pain nurse at 
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08:30 who called
Outreach.
 A - 
Readmitted to ICU
Intubated and ventilated
 B - NS 3LO2 RR,
with high dose inotropes.
SpO2
3rd laparotomy and
 C - BP, HR, colour,
tracheostomy.
skin temp, OU, NG loss
Slow recovery after 14
 D - irritable
days.
 E - NAD
Case study 2
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77 year old man admitted for AP
resection.
12 days post op
MEWS up to 9.
Admitted to ICU 22 hours later.
Case study 2
During 22 hours
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9 entries in notes
9 descriptions of deterioration
4 requests for abdo and CXR
Blood transfusion
More fluids
Observe and review repeatedly
9 hours later, mention of ICU referral
ICU involved 16 hours later (no ICU bed)
Died in ICU 7 hours after admission