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Intensive care unit (ICU)—when to involve 

Intensive care unit (ICU)—when to involve
Chapter:
Intensive care unit (ICU)—when to involve
Author(s):

Stephen Chapman

, Grace Robinson

, John Stradling

, Sophie West

, and John Wrightson

DOI:
10.1093/med/9780198703860.003.0056
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date: 26 October 2021

General points

Ideally, communicate with ICU early, as it is much better that they know about a potentially sick patient who may need ICU input than to find your patient (and you!) in difficulty later on, with no ICU bed.

Scoring systems for the early recognition of sick patients are in use in many hospitals, enabling doctors and nursing staff to readily identify and assess a deteriorating patient, including response to treatment. An example is shown in Table 56.1.

Table 56.1 Scoring system for the early recognition of sick patients

Score

3

2

1

0

1

2

3

HR/min

≤40

41–50

51–90

91–110

111–130

≥131

SBP

≤90

91–100

101–110

111–219

≥220

RR/min

≤8

9–11

12–20

21–24

≥25

Temp/°C

≤35

35.1–36

36.1–38

38.1–39

≥39.1

SaO2

≤91

92–93

94–95

≥96

Supplemental O2

Yes

No

Conscious level

A

V, P, or U

A = alert; V = responds to voice; P = responds to pain; U = unresponsive.

Calculate the NEWS total by the addition of the scores in each column.

Total score 1–4: increase observations to 4–6-hourly.

Total score ≥5 (or 3 in any parameter): increase observations to hourly; contact doctor for urgent review.

Total score ≥7: continuous monitoring of vitals; contact senior doctor for immediate review, including assessment by critical care team.

Respiratory rate is the most sensitive marker of illness severity.

The common situations in which ICU input may be required in relation to respiratory disease are principally those relating to decisions about intubation and ventilation. Most commonly these will be:

  • Respiratory failure (either type I or type II)

    • Exacerbation of COPD (usually type II failure). Patients with COPD admitted to ICU have a hospital mortality of 20–25%. Poor prognostic factors include low baseline FEV1, long-term O2 use, low sodium and albumin, low BMI, poor functional status, and comorbid disease. Age does not add prognostic information

    • Pneumonia (to maintain an adequate pO2—usually type I failure). In this situation, ICU input may not necessarily lead to intubation, as adequate oxygenation may be achieved by the proper use of a non-rebreathe mask, Optiflow (humidified high-flow nasal O2), or CPAP, with the additional benefits of one-to-one nursing. Altered mental state and difficulty clearing secretions may make invasive ventilation necessary

  • Upper airway emergencies

  • ≥1 organ failure (not necessarily with respiratory failure)

  • Sepsis requiring organ support, particularly circulatory support requiring vasoactive drugs

Many factors are considered when assessing suitability for ICU admission including: diagnosis, illness severity, coexisting disease, physiological reserve, prognosis, availability of suitable treatment, response to treatment to date, anticipated QoL, patient’s wishes.

National Early Warning Score (NEWS)

This is an example of a ward-based patient illness severity scoring system. It is used to assist medical and nursing staff in the early identification of sick patients, to enable prompt and appropriate HDU/ICU liaison (see Table 56.1).