What happens in an Intensive Care Unit (ICU) from admission to discharge.

Admission

- What is an Intensive Care Unit (ICU) / High Dependency Unit (HDU)?

The ICU is a ward dedicated to acute care of critical ill patients. Other than specialised, complex medical equipment, there is also a higher nursing and doctor to patient ratio.

At the moment, majority of the ICUs in Singapore are further specialized into Medical, Surgical, Neurological, Cardiothoracic, Pediatric, Burns and Coronary Care. Ng Teng Fong General Hospital and the future Seng Kang General Hospital are two hospitals with combined medical and surgical ICUs.

The HDU is also a ward dedicated to acute care of critically ill patients. HDU patients fall into two categories: patients who no longer need ICU care but not completely ready for the general ward, or patients who are too ill to be managed safely in the general ward but not yet requiring ICU care.

- Why is admission to an Intensive Care Unit (ICU) / High Dependency Unit (HDU) necessary?

Most patients in hospital receive and get better with general ward care. In a small proportion of patients, they require more support than possible in the general wards. These patients are considered for intensive care.

If your relative has:
1. A potentially reversible medical condition
2. Organ failure requiring intensive care support
He may be a candidate for intensive care.

Consideration is also given to his previous state of health and other medical conditions.

There are generally two broad reasons for ICU or HDU admission:

1. Precautionary - for closer monitoring in anticipation of potential medical complications. An example would be ICU/HDU admission after major surgery.

2. Resuscitation - when specialized, complex medical treatment and equipment are needed to keep the very ill patient alive.

- What does an admission to the Intensive Care Unit (ICU) mean to you?

For the family, the ICU environment both is intimidating and trying. The feeling of helplessness and uncertainty very common. You want to know what will happen next. You need to know what to expect.

You wonder about the chances of survival and whether there will be permanent disability. Your doctor and nurse are the best sources of information but it is not possible for the doctor or nurse to accurately predict outcome. There are also some indicators that you can use to help determine the severity of the patient's condition for yourself:

Less worrying:
Only one organ failing (being on a breathing machine, but the heart, kidneys and brain are functioning).
Not needing a breathing machine in two days or less.
Surviving a cardiac arrest and waking up within 1-3 days.
Blood pressure stable and not requiring medications.

Worrying:
Two or more organs failing.
Needing a breathing machine for more than three days.
Surviving a cardiac arrest but not waking up after 3 days.

For the patient, the ICU can be a hectic environment and many ICU procedures and treatment have the potential to cause distress and discomfort. Medications are often used to minimise pain and discomfort, but can result in sedation.

- What happens during admission?

Transfer to the ICU may be planned (elective) or unplanned (emergency).

In an emergency admission, a number of procedures are usually required at the onset. Treatment is started while the patient is closely monitored. Specialized investigations may need to take place before a diagnosis can be made. These interventions will take some time to perform.

- Who looks after the patient/who does what?

Medical Teams

In general, there are at least 2 teams looking after the patient, the ICU Team and the “Primary” Team.

The Primary Team, in most instances, is the General Ward Team or Service the patient was admitted to in the first instance. For example, general surgery, internal medicine or specialities such as respiratory/pulmonary or cardiology.

The ICU Team helps the Primary Team provide critical care for the patient during the ICU stay. The ICU Team is often divided into the Day Team and the Night or On-Call Team.

If the medical condition is complicated, the Primary and ICU Team may enlist the help of other specialist Teams such as Infectious Disease, Cardiology or Surgery.

Nursing

The nurses work on shifts and a senior nurse is assigned per shift to be the “In Charge” or “Charge Nurse”.

A staff nurse will be assigned to the patient and may be termed the “Room Nurse”. Depending on the ICU situation, the Room Nurse may be assigned to the care of up to 2 patients. If the patient’s condition is dire, there may be 2 nurses assigned to the care of a single patient. Assistant nurses may help with some aspects of the patient care.

Paramedical

This comprises of a diverse group of healthcare workers ranging from Respiratory Therapists, Physiotherapist, Occupational Therapists, Speech Therapists, Dietician, Wound Nurses, Stoma Nurses, Radiology and Cardiology Technicians. Each hold a unique skill set to help in the complete care of the patient.

During the Stay

- What is the routine?

The patient is seen by the ICU and Primary Teams in the morning and afternoon. During ward rounds, most hospitals will request for visitors to wait until the round is completed. During the ward round, the events over the day is recounted and plans are made for the day. After the round is completed, the Teams will carry out the plans and visitors are then allowed into the ICU.

The Teams may contact the Next of Kin to discuss the treatment plans or obtain acknowledgment regarding certain procedures, such as the placement of breathing tubes, special intravenous drips, etc.

Family conferences or meetings may take place at variable frequency. During these meetings, the doctors will discuss and update the patients’ conditions and reach a consensus on the treatment plans and goals.

- What common procedures are done?

A wide variety of procedures may be performed as part of the patient’s treatment, but the commonest include the endotracheal intubation, placement of central venous catheters and intra-arterial cannulas, placement of urine catheters, bronchoscopy, paracentesis and chest drain insertion or thoracentesis. (Hyperlink to Procedure glossary)

- What complications may arise from the procedure?

Complications vary from minor to severe and life threatening. The commonest risk include bleeding and infection. Specific risks can be found here (Hyperlink to procedure glossary).

- What does the doctor mean when he/she says “….”?

Although doctors try hard to explain things in simple terms, medical terminology may slip into the conversation. Always attempt to clarify on the spot, otherwise you can find a glossary of terminology here ((Hyperlink to General glossary).

Common ICU Conditions

With modern ICU care, it's becoming less common for patients to die acutely. What is becoming more common is the patient who survives the acute phase of critical illness but develops numerous complications and may never make recover completely.

This is a list of commonly encountered complications within the ICU. In general, the occurrence of these complications increase with duration of hospitalisation and ICU stay.

Confusion or Delirium

Delirium may include periods of confusion with intermittent periods of normal function, poor memory and lack of attention, excessive sleepiness, agitation or hallucinations. The exact cause of delirium is not known but elderly age, severe illness, major surgery, lack of sleep, medications or infection may all contribute. The treatment is aimed at correcting reversible medical conditions and protecting the patient from being injured. If general care fails to control the agitation, medications and temporary restraints may be required to protect the patient from harming himself or herself. Delirium may vary in duration. Some patients may suffer from permanent mental changes after severe illness.

Weakness 


ICU patients are at risk of becoming weak very quickly, due to problems with nerves (known as neuropathy) or wasting of the muscles (known as myopathy).  Weakness may mean that the patient will be dependent on the breathing machine for longer than expected. The exact cause of this type of acute weakness is not known, but it is likely related to widespread inflammation, certain types of drugs (such as steroids), and high blood sugar levels. The focus is on prevention by good nutrition and physiotherapy. There is no specific treatment for ICU related weakness and recovery is known to be slow.

Heart Failure

Heart failure may be the cause of the ICU admission, or it might be affected by other conditions and contribution to the patient’s deterioration. Severe infection is well known to cause heart malfunction. This is usually reversible if the patient recovers from the underlying condition. Drugs are used to boost the blood pressure and improve heart function, but may also cause unwanted side effects.

Infections



Infection means invasion of the body by bacteria, viruses or fungus that cause harm to a person. Many different parts of the body can be infected, but in ICU the most common sites include the lungs, IV tubes, surgical wounds and the bladder.  






Lung or chest infection: Ventilator-associated pneumonia





The main risk factor for a lung infection (also known as pneumonia) is being on a breathing machine. The likelihood of this increase with the duration of breathing support.




IV tube infection: Central line-associated bloodstream infection





The main risk factor for a IV tube infection is the duration in which the tube is in place. Unfortunately these tubes are essential, especially when the patient is very sick.




Surgical site infection





 Many factors contribute to wound infection and repeat surgery may be necessary to control the situation.




Bladder or urine tube: Catheter-associated urinary tract infection





The main risk factor for a bladder infection is the duration in which the urine tube is in place. Unfortunately the urine tube may be essential to ensure that the bladder can empty and for monitoring of urine production.






Treatment: When an infection is suspected, tests are performed and infections are usually treated with antibiotics. In some cases, removal (and replacement) of infected tubes are required.




“Hole in the lung” or Pneumothorax


This condition may arise as a complication of a procedure (central line insertion), due to existing poor lungs or due to high pressures generated by the breathing machine to ensure adequate air exchange. Imagine the lung as a deflated balloon. This condition may be quickly life threatening and is treated by placing a tube into the chest cavity to drain the accumulated gas outside the lung and allowing the deflated lung to re-expand.




Stomach or Stress Ulcers



This occur when the lining of the stomach breaks down due to severe illness and can lead to life threatening bleeding. To prevent this, most ICU patients are treated with medications which lower the amount of acid in the stomach. 
If bleeding occurs, treatment involves medication to reduce the acidity of the stomach or direct treatment using a special camera inserted into the stomach through the mouth. In some situations, surgery may be required to stop the bleeding. 




Ileus or gut failure

Disease of the intestine, severe infection and drugs are some common causes of ileus, also known as gut failure or malfunction. Normally, food and nutrients move from the stomach towards to rectum in an organised fashion.

In ileus, the intestine fail to coordinate and nutrition cannot be absorbed. If there is a surgical cause (for example, blocked intestines), an operation may be needed. If there is no physical blockage, then treating the underlying disease, and the use of some medications to encourage intestinal movement is used.

Dead intestine or ischemic bowel


This is a life threatening condition in which part of the intestine do not receive enough blood supply and die as a result. The dead intestine causes severe pain, low blood pressure and may burst, releasing food material in the abdomen. This is an emergency and urgent surgery is often needed.




Deep Vein Thrombosis (DVT)

A DVT is a blood clot in the deep veins of the leg or groin. It can affect any immobilised patient and is increased in patients with injury, cancer, infections, or genetic reasons. The most serious complication of DVT is pulmonary embolism (PE), when the clot travels into the lung and may be cause death. To prevent DVT, patients are treated with low dose blood thinners, special stockings or machine to compress the calf intermittently.

Kidney Failure

Kidney failure is the inability of the kidneys to remove toxins and fluid from the body resulting in accumulation. There are many causes of kidney failure, including prolonged low blood pressure, infections, or medications. It may be temporary or may become permanent. Toxins and fluid may be removed from the body using machines (dialysis).

Please click here for additional information.

Skin ulcers (pressure ulcers or bed sores)

These are ulcers that are caused by pressure on the skin, especially in the buttock, heel or elbow areas where bones are close to the skin. The main risk factor for developing pressure sores is prolonged immobilisation. Thin patients who have chronic muscle weakness, or who have been hospitalised for prolonged periods of time are at higher risk. This is prevented by frequent turning in bed to relief the pressure on the skin.

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Medication Side Effects


All medications have the potential to cause harmful effects which are not intended. Side effects can be mild (skin rash or diarrhoea) or severe (bleeding, severe allergy or death) and maybe unpredictable.




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Procedural Complications


Most patients in the ICU require procedures to be performed at regular intervals. Most commonly, such procedures involve the placement of lines or tubes, such as feeding tubes, breathing tubes, drainage tubes, or IVs into the deep or superficial veins.

All procedures carry a small risk of complications. All possible measures are taken to reduce the risk of such complications, but the risk is never zero. In the event that a patient requires a procedure (beyond the normal procedures that all patients require), the situation will be discussed with the patient or their family.

 

What If Things Don't Go RIght

Life Choices

Medical technology can prolong life in many situation, but if the underlying condition cannot be reversed it does nothing but to prolong suffering by artificially delaying death and resulting in a huge financial drain that leave the living to suffer. In such situations, a decision needs to be made to determine the extent of care.

It is important for you to know that you and your loved one have options. In Singapore, the decision to limit or withdraw care is often made in conjunction with the family. When faced with critical questions such as these, it becomes very important to put your own feelings aside and to consider the wishes of the patient. The healthcare team will make recommendations regarding the limitation or withdrawal of care. This comes in several forms:

1. Withdrawing of artificial life support.

The patient may be kept alive only by artificial means (with drugs or machines). Withdrawal of life support does not mean giving up. Stopping these artificial interventions is to allow nature to take its course. The patient is still cared for but with the focus on keeping comfortable and as pain-free as possible.

2. Limitation of artificial life support.

There are situations where limitation of the amount or type of life support is reasonable. This can include avoiding high or toxic doses of medications or starting treatment that may cause harm. Treatment limitation may include the limited use of fluid drips and antibiotics.

3. Do not resuscitate (DNR) order.

This means that in the event that the heart stops, chest compressions will not be used to attempt to resuscitate as it may prolong the dying process and cause pain or harm.

We all hope and work towards the full recovery of the patient, but there will be a time where it is difficult or impossible to reverse disease conditions. In this situation, it is important not to cause more pain and suffering by persisting with unnecessary and ultimately futile treatment.

 

Organ Donation

What is organ donation?

• - Organ donation are divided into two categories: living donation and cadaveric donation.
• - Living donation occurs when a healthy person donates an organ (usually kidney) or part of an organ (usually liver) to another person.
• - Cadaveric donation occurs when a person donates his or her organs after the diagnosis of death.
• - Donated organs are transplanted into patients in need and can save or improve lives.

Why donate organs?

• - Organ donation allows the deceased to leave a living legacy. It is also often considered as the “greatest gift one can make”.
• - Organ donation is an act of altruism and can save or improve lives of others. When an individual’s actions are focused mainly on the beneficial impact to others, without regard to the consequences to the individual, the actions are regarded as “altruistic”. Saving a life is regarded as one of greatest good man can achieve.
• - Some experts and philosophers believe that everyone should want to donate organs as it is for the good of the society. In fact, some believe that it is immoral for an individual to decline consent for donation of his or her organs, especially when they no longer have use for them.
• - Major religions encourage altruistic acts, and specifically include organ donation.

Additional resources on organ donation: https://www.liveon.sg/content/moh_liveon/en/index.html

Does my religion encourage or even allow organ donation?

- Yes. All major religions in Singapore approve of organ donation. Some resources include:
Organ Transplant In Islam
Does the Catholic Church allow organ donation?

What is the law of the land?

In Singapore, the Human Organ Transplant Act (HOTA) is based on “implicit consent”, that is to say: consent without some specific move denoting consent, and inaction is itself a sign of consent. In simpler terms, everyone who qualifies is a potential organ donor if they are diagnosed with brain death and have not previously registered their objection officially.

HOTA covers all Singapore Citizens and Permanent Residents 21 years old and above, who are not mentally disordered and to come into effect when the diagnosis of brain death is made. The criteria of brain death is stringent and internationally recognized to protect the interest of the patient.The only organs covered under this Act are the kidneys, liver, heart and corneas.

Actual HOTA document: Human Organ Transplant Act (CHAPTER 131A)

The Medical (Therapy, Education and Research) Act (MTERA) is based on based on “explicit consent”, that is to say an opt-in scheme, where people pledge to donate their organs and tissues (e.g. kidney, liver, heart, cornea, lung, bone, skin, heart valves, etc) for the purposes of transplantation, education or research after they pass away.

Anyone 18 years old and above, and are not mentally disordered can pledge to donate all his or her organs or specify which to donate. In cases where a person had not pledged his/her organs under MTERA before passing away, the family members donate the organs on their behalf under MTERA if they wish to do so.

Actual MTERA document: Medical (Therapy, Education and Research) Act (CHAPTER 175)