Treatment and Recovery
Treatments and procedures in an ICU
Intensive care units offer a large number of treatments that cannot be given on normal wards. Such treatments include:
- continuous invasive monitoring (invasive means plastic cannulas or tubes are put into the veins and arteries to enable blood pressure and blood flow to be measured) sometimes pressure recorders are put into the head to measure pressure inside the head in patients with head injuries or after surgery (so further treatments can be started to lower the pressure if it is going too high); drainage tubes may be put into the bladder (urinary catheters) and tubes into the stomach, usually through the nose (nasogastric tube).
- support of breathing (ventilation) either via a tight fitting face mask or through the insertion of a breathing tube in the windpipe (tracheostomy).
- performing tracheostomy (where a breathing tube is put through the front of the patient's neck into their windpipe. Once in, this is much more comfortable and patients' sedation can be reduced and often stopped).
- support of the circulation when the blood pressure is low using fluid replacement and drugs that increase blood pressure (inotropes and vasopressors).
- kidney support (dialysis or more often "haemofiltration") which takes over the function of the kidney in patients with kidney failure.
- nutritional support either feeding through via nasogastric tubes or if a patient's digestive system is not working, directly into the veins.
- inserting lines for giving drugs and measuring pressures.
Who decides on treatments and treatment limitations?
Whenever a patient is able to discuss and decide on their own treatment the patient decides. Doctors are there to advise and help, but the decisions are up to the patient. On intensive care patients are usually unable to discuss their treatment and are often heavily sedated. The doctors and nurses will always explain what they are doing to a patient even if they don't appear to be able to hear.
Emergency treatments are simply done to provide the care necessary to keep patients alive. For planned procedures and major interventions there will usually be a discussion with and information given to the family and next of kin as this is what most patients would want to happen. The ultimate decision traditionally rests with the medical team caring for the patient.
There has recently been a change to the law in this area with the Mental Capacity Act. If a patient has nominated a Designated Decision Maker through a Lasting Power Of Attorney or a Court Appointed Deputy then this person now has the final say in whether a procedure can go ahead and can speak on behalf of the patient in the same way that the patient would normally decide for themselves, that is they can give consent for a procedure in the way a patient normally would.
Some patients decide in advance that there are specific situations in which they would not want certain treatments. "Advance directives" or "Living wills" as they are sometimes called are now legally binding. It is however important to realise that these documents need to be very specific in the circumstances and treatments they describe for them to apply.
The medical teams will always try to do what a patient wants and act in accordance with their wishes whenever possible, but they will not and should not offer treatments that they believe to be futile or harmful and this includes treatments that will prolong life or suffering when there is no longer any chance of recovery. These are very difficult areas and the doctors will always discuss these decisions in great detail with patients and their families. If you have specific concerns around these areas then talk to your doctors.
When patients are sick for a long time or their immune system is not working well, and especially if they need lots of antibiotic treatments, they become vulnerable to acquiring new infection. There are lots of measures taken in intensive care to minimise these risks but they cannot be removed completely. For example, having a breathing tube in the windpipe is essential if a patient is unable to breath without assistance, but at the same time it breaks the body's natural barriers to keeping bacteria out of the lungs and patients become vulnerable to "ventilator associated pneumonia". Similarly having the tubes in veins gives the bacteria a route of entry through the skin that isn't normally there.
Unfortunately in hospitals the necessary use of antibiotics means that the bacteria get used to them and become resistant. MRSA (methicillin resistant staphylococcus aureus) is an example of such an organism, staph aureus is a bacteria that is commonly carried on the skin and around the nose by healthy people, MRSA is just the same bug but is able to resist treatment with many antibiotics (originally methicillin which is a bit like penicillin). Being aware of the organisms around enables us to treat patients who develop infections and who might be carrying resistant versions with the right antibiotics. The difficulty comes when the antibiotics available to treat the resistant bugs aren't always as effective at killing them.
Hygiene is therefore very important to try to prevent patients carrying infection, but it should be remembered that many patients have been unwell before and arrive in the hospital or on the intensive care unit already carrying the infection with resistant bacteria that were just not known about.