Treatment on the ICU

John Farman Intensive Care Unit

Details of treatments

Treatment that a patient may receive on the ICU can involve the use of specailist equipment that is designed to aid the patients recovery.

Treatment includes the use mechanical ventilator to assist breathing through an endotracheal tube or a tracheotomy opening, dialysis equipment for renal problems, equipment for the constant monitoring of bodily functions, a web of intravenous lines, feeding tubes, nasogastric tubes, suction pumps, drains and catheters, and a wide array of drugs to treat the main condition(s), induce sedation, reduce pain, and prevent secondary infections.

Consent to Treatment

How can patients or next of kin give consent for treatment?

Most patients in intensive care are too unwell to know what is happening to them, and even if they did know they are often unable to communicate. Because of this, it is impossible for us to obtain the patient's consent should it become necessary to do some kind of operation or procedure.

Under UK law, no-one may give consent on behalf of another adult, not even the next-of-kin.

It is our duty as ICU staff to do what we believe is in the patient's 'best interests', which means that we need to find out as best as we can, given the patient's wishes and religious or other beliefs, what the patient would have wanted us to do. In order to do this properly we always try to discuss any plan for surgery with the patients next-of-kin (except in life-threatening circumstances), so that we can decide what the patient's 'best interests' are.

> Consent forms

Monitors

Monitoring a patients progress

One of the principal reasons to admit a patient into an intensive care unit is to be able to keep a very close eye on their progress. To do this, most patients are connected to several different types of monitor, which continuously measure important aspects of the patient's well-being. The most common types of monitoring are:

Heart monitoring: Wires are often connected to small round adhesive pads stuck on the chest or arms. These pick up the electrical activity of the heart, which is displayed on the monitor as an electrocardiograph. Next to the ECG trace on the monitor will be displayed a number, which is the patient's heart rate.

Blood pressure (and blood samples): A small plastic tube is inserted painlessly using local anaesthetic into an artery, either at the wrist or in the groin, allowing the blood pressure to be measured continuously. This can also be used to take blood samples painlessly and quickly.

Fluid levels: A slightly larger plastic tube (again, inserted painlessly using local anaesthetic) lies in a big vein (either on the side of the neck, or just below the collarbone). On the outside of the patient, this tube often divides into three or four smaller ones. One of these is likely to be used to measure the central venous pressure (CVP), which is an indication of how much fluid the patient needs (a bit like the gauge on the side of an oil tank). The other tubes can be used to deliver drugs such as sedatives, analgesics or antibiotics. These tubes are also used to infuse any drugs used to support the heart and circulation.

While a patient is on the ICU, the lines and numbers on the monitors change continuously. This can be alarming to visitors. Do ask the nurse to explain what they mean. There is no need to watch the monitors or worry about what they are reading.

Dialysis

Some patients develop kidney failure during their illness, and the work of the kidneys is then done by a special machine that filters the body's waste products out of the blood, just like the kidney.

Depending on the type of filter used, this process is called haemofiltration or haemodiafiltration. Both techniques are used on the John Farman ICU.

Do ask the nursing staff to explain why and how these are being used. Kidneys can fail temporarily, and needing to have some dialysis on the Unit doesn't mean the patient will always have to be dialysed.

> Renal services (Nephrology)

Ventilators

Ventilators (breathing machine or life support machine)

The majority of critically ill patients require at least some help with their breathing, and this is provided by a machine called a ventilator ('breathing machine' or 'life support machine').

The ventilator blows fresh air and oxygen into the patient's lungs, and then lets it out again, in exactly the same way as would occur naturally (called mechanical ventilation).

Because having a tube in the mouth (called an 'endotracheal tube') for extended periods is uncomfortable, patients who require ventilation are often given drugs to make them sleepy, called sedatives. The tube will be held in place by cotton ribbon which is tied behind the patient's neck. Patients can be ventilated for several days using a tube in the mouth, but sometimes it is preferable to use a tracheostomy (see below).

Tracheostomies

About Tracheostomies

Most patients on the ICU have difficulty breathing for themselves and, therefore, need help at some point from artificial breathing machines (called ventilators - see above). These machines are connected to the patient's lungs using a plastic tube that is inserted through the mouth (but sometimes through the nose).

Some patients will need their breathing to be supported for several days or more. These patients can benefit from having the tube in their mouth or nose changed to a shorter tube that is placed directly into the windpipe through the front of the neck. This is known as a tracheostomy and has several advantages:

A tracheostomy makes it easier to keep a patient's lungs clean, which is important for their health.
Tracheostomies are more comfortable for patients than having a tube in the mouth or nose. Therefore, patients can need less of the drugs that make them sleepy, which is better for their health in the medium to long term.
Tracheostomies can make it easier to 'wean' some patients from the ventilator.

Occasionally, a tracheostomy is needed for other reasons, which will be explained to you by the ICU staff.

Because a patient is in ICU does not mean they will have to have a tracheostomy.

What's involved

A tracheostomy requires a short operation, which is done either in the operating theatre by the ear, nose and throat surgeons (called a surgical tracheostomy) or on the John Farman ICU by the ICU consultants (called a percutaneous tracheostomy).

Which type is best?

A percutaneous tracheostomy has the advantage that the patient does not need to be moved to the operating theatre, but a surgical tracheostomy is safer in patients with shorter or fatter necks, or in those who have blood clotting problems.

What is a percutaneous tracheostomy?

A percutaneous tracheostomy is the type performed by ICU consultants on patients staying in the ICU.

Are there any risks associated with a tracheostomy?

As with any technique undertaken on patients staying in intensive care, there are always some associated risks. The main serious risks associated with a tracheostomy occur during or soon after the operation and are:

A decrease in the amount of oxygen in the blood.
Bleeding in the neck area.
The development of an air leak from the lungs.
Damage to the windpipe.
Displacement of the tube.
Infection.

We can monitor patients for these complications and take steps to treat them if they occur. These complications are not common but they can have serious implications and the ICU consultants take the risks into account before a tracheostomy is sited. The decision to perform a tracheostomy is only taken if the benefits to the patient are greater than the potential risks.

What are the long-term effects of a tracheostomy?

When the patient no longer needs their tracheostomy, it is simply removed and the hole is covered with an air-tight dressing. Within a short space of time (one to two weeks) the hole closes and heals over, leaving a tiny scar. Very occasionally, a small dimple remains at the old tracheostomy site. This can easily be removed, if necessary, by a plastic surgeon.

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