Monitoring and

management of critically
ill patients
Monitoring of critically ill patients in CCU
• Critical care unit:
• As “It is an organized system for the provision of care to critically ill patients
that provides intensive and specialized medical and nursing care, an enhanced
capacity for monitoring, and multiple modalities of physiologic organ support
to sustain life during a period of life-threatening organ system insufficiency.“
• Purpose of monitoring critically ill patients:
to prevent a progressive deterioration in the physiologic state of a patient as the
underlying disease is being managed.
ensuring patient safety through awareness of critical changes in the patient’s health
status,
 it guides daily therapeutic interventions.
SYSTEMS TO BE
MONITORED :
CARDIOVASCULAR SYSTEM MONITORING

RESPIRATORY MONITORING

CENTRAL NERVOUS SYSTEM MONITORING

RENAL SYSTEM MONITORING

HEPATIC SYSTEM MONITORING

HEMATOLOGICAL MONITORING
CARDIOVASCULAR MONITORING
• It includes:
• CONTINUOUS CARDIAC
MONITORING
• 12 LEAD ECG
• Mucous membrane color
• Capillary refill time
Continuous cardiac monitoring
Cardiac monitoring describes the continuous monitoring of an ECG
which is then displayed by the patient bed side, usually with a
duplicate display at a central nurses’ station.
The goal of continuous ECG monitoring is to aid in:
 (a) immediate recognition of sudden cardiac arrest to improve time to
defibrillation;
 (b) recognize deteriorating conditions such as early after-depolarizations or
non sustained arrhythmias that may lead to a life-threatening arrhythmia;
 (c) facilitate management of arrhythmias; and
(d) diagnose arrhythmias or aid in identifying the cause of symptoms (such as
syncope and palpitations) and help guide management.
• 12 LEAD ECG:  The standard 12-lead electrocardiogram is
a representation of the heart's electrical activity recorded from
electrodes on the body surface.
• Mucous membrane color: normal color is pink. In diseased
state color may be yellow, pale, white, brick red or blue.
• Capillary refill time: it is an indicator of peripheral perfusion.
 It is the rate at blood returns to capillary bed after it has been
compressed digitally.
Normal CRT is 1-2 seconds.
Prolonged CRT is due to vasoconstriction.
HAEMODYNAMIC MONITORING
• Definition:
• Hemodynamic monitoring is measurement of pressure, flow and oxygenation
of blood within cardiovascular system.
OR
• Using invasive technology to provide quantitative information about vascular
capacity, blood volume, pump effectiveness and tissue perfusion.
OR
• Measurement and interpretation of biological systems that describes the
performance of cardiovascular system.
 Non-invasive Blood
Non-invasive Pressure Measurement

NON-INVASIVE METHODS
methods ECG
 These methods does not require any
device to be inserted into the body
hence does not breach skin. Chest X-Ra
 Directly measured non-invasive
variables are:
o Body temperature
o Heart rate
Pulse oxymetry
o Blood pressure
o Respiratory rate
 Non-invasive blood pressure ECHO
monitoring is by use of
sphygmomanometer.
 Impedence cardiography is Impedence
continuous noninvasive method of cardiography
obtaining CO and assessing thoracic
fluid status.
Invasive Arterial blood

INVASIVE METHODS
pressure monitoring

methods Central venous

It consists of percutaneous pressure monitoring
insertion of a cannula into a
peripheral artery identified Pulmonary artery
either by palpation or under pressure monitoring
ultrasound guidance.
The common sites for arterial Venous oxygen
cannulation include radial, saturation monitoring
ulnar, brachial, axillary,
femoral and dorsalis pedis
arteries.  Cardiac output
• Arterial blood pressure monitoring: it is indicated for patients with
acute hypertension and hypotension, respiratory failure, shock,
neurologic injury, coronary interventional procedures, arterial blood
gas [ABG] sampling.
• Coronary venous pressure monitoring: CVP is a measurement of right
ventricular preload and reflects fluid volume problems. It is most
often measured with central venous catheter placed in the internal
jugular or subclavian vein.
• Pulmonary artery pressure monitoring: PA diastolic pressure and
PAWP are sensitive indicator of cardiac function and fluid volume
status. Fluid therapy based on PA pressures while avoid under
correction or overcorrection of the problem. Monitoring PA pressures
permits precise therapeutic manipulation of preload.
• Venous oxygen saturation monitoring: the O2 saturation of the blood
from PA catheter is termed as mixed venous oxygen saturation. Its
measurement is useful in determining the adequacy of tissue
oxygenation
Respiratory
monitoring
Respiratory ARTERIAL BLOOD GAS ANALYSIS

insufficiency is one
of the main reason PULSE OXYMETRY
of admission to ICU,
it must be VENTILATION MONITORING
monitored carefully.
• Pulse oximetry: Pulse oximetry is a noninvasive and painless test
that measures your oxygen saturation level, or the oxygen levels in
your blood.
• Normal SpO2 is 95% to 100%.
• Arterial blood gas analysis: An arterial blood gases (ABG) test is a
blood test that measures the acidity, or pH, and the levels of oxygen
(O2) and carbon dioxide (CO2) from an artery. The test is used to
check the function of the patient’s lungs and how well they are able
to move oxygen into the blood and remove carbon dioxide.
• Ventilator monitoring:  enables us to understand the functional
status of a ventilator system and the ventilated patient.
Central
nervous CEREBRAL
INTRACRANIAL
PRESSURE
MONITORING

system NEUROLOGICAL
OBSERVATION
FUNCTION
MONITORING

monitoring
 consciousness

Limb Neurological Glasgow

movement observation coma scale

Pupillary
assessment
Consciousness
• Consciousness is the most sensitive indicator of neurological change
and usually the first to noted.
• Definition: Consciousness describes our awareness of internal and
external stimuli.
• The methods of assessing consciousness are:

AVPU

GLASGOW COMA SCALE

Cerebral function monitoring
• Use of continuous EEG monitoring to assess and monitor a patient
with brain injury or acute ischemia enables prevention of further
complications.
• ELECTROENCEPHALOGRAPHY [EEG]: it is a method to record an
electrogram of the spontaneous electrical activity of the brain.
Intra-cranial pressure
monitoring
• Intracranial pressure monitoring is standard for patients with severe
closed head injury and is occasionally used for some other brain
disorders, such as in selected cases of hydrocephalus and idiopathic
intracranial hypertension.
• These devices are used to monitor ICP and to optimize cerebral
perfusion pressure. Typically, the cerebral perfusion pressure should
be kept > 60 mm Hg.
• Devices used are:
Extra ventricular drain (EVD)
 intraparenchymal monitor,
 subarachnoid bolt,
 subdural bolt,etc.
Renal system monitoring
• Fluid monitoring [intake –output chart]
• Assess glomerular filtration rate: ;ower the gfr worse is the kidney
function.
• Creatinine clearance
Hepatic system monitoring
• Prothrombin time is useful marker for monitoring liver functions.
• Upon the arrival of a liver transplant recipient in the ICU,
advanced monitoring, which estimates CO and volume status,
additionally to standard hemodynamic monitoring, that is
electrocardiogram, pulse-oximetry, and invasive blood pressure,
are deemed essential.
Hematological monitoring
• Blood test conducted are :
 patients need a daily set of electrolytes and a complete blood
count (CBC).
Patients should also have magnesium, phosphate, and ionized
calcium levels measured.
Patients receiving total parenteral nutrition need weekly liver tests
and coagulation profiles.
 Other tests (eg, blood culture for fever, serial CBCs for possible
active blood loss]) are done as needed.
Blood glucose test, cardiac biomarkers, ABGs, etc.
NEAR INFRARED SPECTROSCOPY
• NIRS is a noninvasive method of continuously monitoring
end organ oxygenation and perfusion.
• NIRS sensors are usually placed on the skin above the target
tissue to monitor mitochondrial cytochrome redox states,
which reflect tissue perfusion.
• It is used to monitor:
acute compartment syndromes (eg, in trauma)
 in postoperative monitoring of lower-extremity vascular bypass
grafts.
CRITICAL CARE
SCORING
SYSTEMS
Critical care scoring systems
• Illness severity scoring systems are commonly used in critical care.
When applied to the populations for whom they were developed and
validated, these tools can facilitate mortality prediction and risk
stratification, optimize resource use, and improve patient
outcomes.
• Several scoring systems have been developed to grade the
severity of illness in critically ill patients.
• these systems are more valuable for monitoring quality of
care and for conducting research studies because they allow
comparison of outcomes among groups of critically ill patients
with similar illness severity.
Acute Physiology and Chronic Health
Evaluation 
• The APACHE II is measured during the first 24 h of ICU admission; the maximum
score is 71.
• incorporating only 17 variables to provide a score between 0 and 71. The
worst values over 24 h are included to calculate a score that translates to
mortality risk.
• A score of 25 represents a predicted mortality of 50% and a score of over 35
represents a predicted mortality of 80%.
• APACHE 3 includes 26 variables
• APACHE 4 includes 142 variables.
•  The APACHE score is an admission score, and therefore, does not take into
account any resuscitative or therapeutic efforts before ICU admission.
National Early Warning Score (NEWS)
• The NEWS is based on a simple aggregate scoring system in which a score is
allocated to physiological measurements.
• The NEWS score identifies the patients at risk of deterioration and facilitates
prompt critical care intervention.
• Six simple physiological parameters form the basis of the scoring system:
1.respiration rate
2.oxygen saturation
3.systolic blood pressure
4.pulse rate
5.level of consciousness
6.temperature.
• The score is then aggregated and uplifted by 2 points for people requiring
supplemental oxygen to maintain their recommended oxygen saturation.
SEQUENTIAL ORGAN FAILURE
ASSESSMENT SCORE
• The SOFA score is based on six different independent scores,
including respiratory, cardiovascular, hepatic, renal, coagulation, and
neurological systems, and is used to check the patient’s status or the
extent of organ failure and dysfunction in intensive care units
(ICUs). Generally, it is designed to predict the mortality but not the
success or failure of medical interventions.
• SOFA incorporates the physiological derangement of six organ
systems, where each organ system is given a score between 0
(normal function) and 4 (grossly abnormal) to give an overall
score of 24.
)
Score
Organ system Variable
0 1 2 3 4
Lowest Pao2/ <200 (26.7) (with <100 (13.3) (with
Respiratory Fio2 ratio mm Hg ≥400 (53.3) <400 (53.3) <300 (40) respiratory respiratory
(kPa) support) support)
Platelets
Coagulation ≥150 ≤150 ≤100 ≤50 ≤20
(×103 μl−1)
Highest bilirubin
Liver <20 20–32 33–101 102–204 >204
(μmol L−1)

Dopamine <5 or Dopamine >5 or Dopamine >15 or

adrenaline ≤0.1 adrenaline >0.1
Blood pressure dobutamine any
Cardiovascular status MAP ≥70 mm Hg MAP <70 mm Hg dose (μg or noradrenaline or noradrenaline
≤0.1 (μg >0.1 (μg
kg−1 min−1)
kg−1 min−1) kg−1 min−1)

Central nervous Glasgow Coma

system Scale 15 13–14 10–12 6–9 <6

Highest creatinine
concentration
300–440 >440
Renal (μmol L−1) <110 110–170 171–299
Total urine output <500 <200
(ml [24 h]−1)
 qSOFA score
•  to identify the patients with the highest probability of poor outcome
associated with sepsis, a bedside clinical score named as qSOFA was
developed,
•  which is based on at least two of the following clinical criteria:
• Respiratory rate of 22 breaths/min or greater
• Systolic blood pressure of 100 mmHg or less
• Altered mentation with Glasgow Coma Scale/Score of 14 or less
Glasgow
coma scale
Early
management of
critically ill
patient
• Bedside examination for cardinal features of critical illness
AIRWAY
ASSESSMENT MANAGEMENT
1. Assess the airway: Assess for potential risks to the airway and
• Partially obstructed: diminished level of difficulties in airway management.
consciousness and noisy breathing. ● Call for help early.
• Stridor: obstruction at larynx. ● Start basic airway maneuvers (e.g. head tilt, chin
• Snoring: tongue obstructs the larynx. lift).
• completely obstructed airway: paradoxical ● Suction.
movement of the chest and abdomen with ● Remove foreign bodies.
no detectable movement of air at the ● The use of airway adjuncts, surgical airways and
mouth. endotracheal intubation needs to be
2.  Determine if patient can speak. performed.
3. Inspect for secretions or foreign bodies. ● Treat the underlying cause, if known.
● Check for signs of airway obstruction.
It is important to remember that life-saving
oxygenation and ventilation can usually be
achieved with a simple airway opening maneuver
and the application of mask-bag ventilation
Breathing
ASSESSMENT MANAGEMENT
1. Vital signs (respiration rate, O2 saturation). ● Apnea requires bag-valve-mask ventilation.
● Signs of increased work of breathing. ● Specific conditions require immediate
● Reduced air entry or abnormal breath sounds treatment:
on auscultation. ❖ Tension pneumothorax: Perform a needle
decompression or thoracostomy followed by
chest tube
❖ Bronchospasm: Administer bronchodilators
❖ Hypoxia: Administer O2
❖ Anaphylaxis: Administer IM epinephrine.
• COPD: initially oxygen therapy should be
commenced at approximately 40% and
titrated upwards if saturations fall below 90%
and downwards if the patient becomes
drowsy or if the saturation exceeds 93–94%.
• Respiratory distress: a minute ventilation of
30 liters/min
Bag valve
mask
ventilation
 Circulation
ASSESSMENT MANAGEMENT
1. Assess vital signs:(heart rate, blood • Two large bore intravenous lines should be
pressure, capillary refill time). rapidly inserted and carefully secured.
2. ● Check volume status: • Usually veins in the antecubital fossa are
❖ Hypervolemia (e.g. edema, extra heart easiest to access; blood for urgent
sounds, jugular-venous distension) laboratory analysis may be drawn through
❖ Hypovolemia (e.g. decreased skin these lines.
turgor, delayed capillary refill, dry mucous • Identify the type of shock, then treat.
membranes) • In the event of a hypertensive emergency,
3. Auscultate for abnormal heart sounds. administer IV antihypertensives.
• Circulatory shock is associated with an • fluid challenge: If circulatory shock is
altered mental state, prolonged capillary suspected, This should take the form of
refill, tachycardia, hypotension and rapid, i.e. over 10–15 minutes,
oliguria\anuria. administration of 250 ml of crystalloid or an
equivalent volume of colloid.
Disability
Glucose: measure the patient's blood glucose for abnormalities. If blood glucose levels are
low, oral or intravenous glucose can be given. If the blood glucose is elevated, check ketone
levels which if also elevated may suggest a diagnosis of diabetic ketoacidosis (DKA).

ACVPU: use the ACVPU scale to rapidly undertake the patient's level of consciousness. If a
more detailed assessment of the patient's level of consciousness is required, use the
Glasgow Coma Scale.

Pupils: assess the size and symmetry of the pupils. Examine the pupillary reaction to light.
 Exposure
Assessment MANAGEMENT
● Vital signs (i.e. temperature, weight for ● Remove possible allergens or contamination
pediatric patient). sources (e.g. cholinergic toxins can affect
● Collect a SAMPLE history and perform a full- providers; consider personal protective
body examination for signs of a possible equipment for possible infectious disease).
underlying etiology. ● Provide patient with clean clothes/a hospital
gown.
● In the event of hypothermia, offer a warm
blanked and warm IV fluids, as well as antipyretics
if indicated
● In the event of hyperthermia, consider cold
sponging and give antipyretics.
● Administer specific treatments if the diagnosis is
known.
 SAMPLE history format

S Signs and symptoms Patient/family, other members of staff report of signs and symptoms

A Allergies Important to prevent harm; may also suggest anaphylaxis

M Medications Obtain a full list of current and most recent medications or any dose
changes

P Past medical history Obtaining a past medical history can help in understanding the illness

Take note of the patient's last oral intake, whether solid or liquid; it may
L Last oral intake indicate a risk of vomiting or choking if the patient needs to be sedated,
intubated or to undergo any surgical procedure

Events surrounding the Helpful cues/clues can help to determine progression and severity of
E injury/illness illness.
CIRCULATORY ASSIST DEVICES
• Mechanical CADs are used to decrease cardiac work and improve
organ perfusion in patients with heart failure when conventional drug
therapy is no longer adequate.
• All the CADs
Decrease cardiac workload
Increase myocardial perfusion
Augment circulation
INDICATIONS FOR CIRCULATORY
ASSISSTED DEVICES

• The left, right, or both ventricles require support while recovering

from acute injury
• The patient must be stabilized before surgical repair of the heart.
• The heart has failed, and the patient is waiting for cardiac
transplantation.
 TYPES OF
CIRCULATORY
ASSISSTED
DEVICES

Intra aortic Ventricular

balloon pump assist devices
Intra aortic balloon pump: • Ventricular assist devices:
It provides temporary circulatory VADs are inserted in the path of
assistance to the sick heart by flowing blood to augment or
reducing afterload and replace the action of heart .A VAD
augmenting the aortic diastolic is a temporary device that can
pressure resulting in improving partially or totally support
coronary blood flow. circulation until the heart recovers
or a donor heart is obtained.
summarization
• In critical care, the monitoring is essential to the daily care of ICU patients,
as the optimization of patient’s hemodynamic, ventilation, temperature,
nutrition, and metabolism is the key to improve patients' survival.
• Monitoring and Testing the Critical Care Patient
Blood Tests
Respiratory monitoring
Cardiac Monitoring
hemodynamics Assessment
Central nervous system examination
Renal system monitoring
Hepatic system monitoring.
• Several scoring systems have been developed to grade the
severity of illness in critically ill patients.
APACHE 2
APACHE 3
APACHE 4
NEWS
SOFA
qSOFA
• Early management of critically ill patients:
A: airway
B: breathing
C: circulation
D: disability
E: exposure
RECAPITULIZATION
• What is purpose of monitoring critically ill patients?
• Enlist the systems monitored to assess the critically ill patients?
• What are non-invasive methods of hemodynamic monitoring?
• What is purpose of critical care scoring?
• What is purpose of SOFA score?
• What is ABCDE management ?
• Enlist types of circulatory assist devices?
BIBLIOGRAPHY
Lewis L. Sharon,Dirkson
Ruff Shannon; Medical-Surgical Nursing, volume 2; published by Elsevier. Pag
e no. 1664-1680.
Brunner and Suddharth’s
; Medical-Surgical Nursing, south Asian edition; published by wolters Kluwer .
 WEBSITES:
Scoring systems in the critically ill: uses, cautions, and future directions - BJA E
ducation
ABCDE Approach – CanadiEM
Using the ABCDE approach for all critically unwell patients | British Journal of
Healthcare Assistants (magonlinelibrary.com)
ABCDE management of a critically ill patient (2023) | OSCEstop | OSCE Learni
ng