The Intensive Care Unit

Catheters, machines, sounds, and teams… ICU 101

The intensive care unit (ICU) is the area where your loved one will likely go after being successfully resuscitated from cardiac arrest. We know that your time in the ICU can be overwhelming and can sometimes feel as if you are stepping into a completely different world. There are multiple things going on at once, different sounds and alarms going off, and this may raise questions regarding the various machines in the room, treatment protocols, types of doctors, and devices connected to your loved one during their ICU stay.

Types of ICUs

There are different types of ICUs, and which one your loved one goes to will depend on active medical or surgical needs as well as bed availability. Regardless of the type, the information provided below applies to all.

Types of ICU:

• • Medical ICU (also called “MICU”)
  • Surgical ICU (also called “SICU”)
  • Cardiac ICU (also called “CCU”)
  • Cardiothoracic ICU (also called “CTICU”)
  • Neurocritical care ICU (also called “NICU”)

What are all these machines, tubes, and monitors in the room?

Advanced machines or procedures are placed by doctors if the body needs extra support or for close monitoring. The goal of the ICU is to maintain close monitoring by the medical team so that they can promptly act if something changes in the patient’s medical status. Some of the standard procedures, machines, and devices that you will encounter in the ICU are:

• • Mechanical ventilation or breathing support: A mechanical ventilator, also known as a breathing machine, will be connected to a breathing tube also known as an endotracheal tube (ET tube) that will be inserted into the airway through the mouth. This tube and breathing machine will assist in breathing and maintaining oxygen levels. During cardiac arrest, the lungs may need extra help with breathing, and an ET tube is part of the resuscitation efforts. Sometimes, particularly if your loved one remains unconscious, the breathing machine is maintained in the ICU. Both the ET tube and ventilator machine are temporary and can be removed once someone regains consciousness and can safely take breaths on their own. If the lungs or brain don’t recover as expected to maintain the breathing process, another procedure known as a tracheostomy is performed after 10-14 days of ET tube placement. A tracheostomy is also a temporary device that can be in place for months but can easily be taken out when your loved one has regained their capacity to breathe without help.
• • Vital signs monitor: A screen, usually located next to the bed, displays multiple numbers known as “vital signs.” Vital signs such as oxygen levels, heart rate, respiratory rate, and blood pressure, amongst other parameters, are continuously monitored and displayed on this screen. Medical teams are alerted if any of them move out of range. 
• • Heart monitor leads: Small, sticky pads with thin wires will be placed on the chest in order to monitor the heart’s electrical activity continuously. Think of this as a continuous electrocardiogram (EKG).
• • Pulse oximeter: A sticky sensor that is attached to a finger, earlobe, or even toes continuously monitors the oxygen levels in the blood and can quickly alert the medical team when your loved one’s oxygen levels drop to an unacceptable range.
• • Blood pressure cuff: Also called “BP cuff.” This device is placed on the arm or leg to measure the current blood pressure. You may hear the cuff inflate every few minutes, and the blood pressure obtained will be displayed on the vital signs monitor.
• • Intravenous lines: Also called “IV lines.” These are small catheters that go into the arm and leg veins and give the medical team access to quickly give medications or fluids.
• • Central venous line: A central venous line is larger than IV lines and is inserted into one of the large veins in the body so that the medical team can administer certain important medications.
• • Arterial line: An arterial line (also called “a” line) is a small catheter inserted into an artery (usually in the arm, groin, or armpit) and helps measure blood pressure in a more precise manner than a BP cuff. This type of catheter is usually inserted when clinicians need to maintain very strict blood pressure ranges or frequently check oxygen levels in the blood.
• • Foley catheter: A Foley catheter is inserted into the urethra and helps drain urine into a bag. The doctors may need to keep track of fluids going in and out (usually referred to as “ins and outs”) of your loved one’s body, and this catheter will help them monitor that.
• • Feeding tube: Your loved one will not be able to eat through their mouth while they are intubated, unconscious, or deeply sedated, so a feeding tube where nutrition is provided will be required. A temporary feeding tube (also called nasogastric or orogastric tube) is usually inserted in the nose or mouth and advanced to the stomach or intestine. Special feeding formulas that look like protein shakes, as well as some oral medications, can be given through it. Once your loved one can safely swallow, the tube will be removed.
• • Dialysis machine: If the kidney function deteriorates, which may happen sometimes, the doctors might need to start temporary dialysis to help “clean the blood” and remove toxins from the body so that they don’t build up. Dialysis is either performed every other day or continuously (24 hours a day). This will depend on how stable the vital signs are and what doctors determine the brain and body can tolerate. Dialysis is usually done through a catheter inserted in the neck or groin.

Daily rounds and different medical teams

There will likely be more than one medical team caring for your loved one during the ICU stay. The ICU team is often composed of an attending doctor, training doctors (residents or fellows – doctors that have finished medical school and are in training for their desired specialty/subspecialty), medical students, pharmacists, nutritionists, and nurses. They will be the “primary team” or the team in charge, which means they will be the ones responsible for the overall care and final medical decisions/orders regarding your loved one’s care. There will be many more healthcare workers involved in the care such as consulting physicians (doctors from other specialties who are called by the ICU team to help with specialty-specific issues), social workers, case managers, physical and occupational therapists, exercise physiologists, speech therapists, and respiratory therapists, amongst others.

The ICU team usually works in shifts, a day shift and a night shift. Each shift is usually 12 hours long and though it is still the same team structure, the staffing of the members may vary. The ICU team will evaluate your loved one early in the morning when their shift starts and review the chart and overnight updates and events. During morning rounds, the entire team with the attending physician as the leader of the team will discuss your loved one’s case, review labs and imaging results, and consider recommendations made by the consultants. Based on this combined information, they will make decisions regarding the next steps in the care plan and talk to you or other family members if present at the bedside or plan to call you in the afternoon for updates. The ICU team is the best team to direct your questions to, as they will have a better picture of your loved one’s case and progression and give a more informed answer. However, you can and should still ask consultants specific questions you have for them. After the morning rounds (which should end around noon), the ICU team will proceed to call consultants, review new labs or imaging results, perform procedures, and receive phone calls from families looking for daily updates. Consulting physicians (i.e., cardiology, neurology, nephrology, infectious diseases, etc.) will also be visiting in the afternoons if the ICU team has requested their help in your loved one’s care. 

When the day shift ends (usually between 6-7 PM) the night shift doctors and nurses will arrive and receive updates (also called “sign-out”) from the day shift team on all the patients they are caring for. This way, the night shift is aware of things to look out for, diagnostic tests to follow up on, consultants to follow up with, or specific actions that need to occur overnight. You can also call the night shift team anytime to receive updates.

Commonly used ICU medications

The type and dosage of the medications given will depend on what the needs are and how sick someone may be. Most medications will be injected through the IV or central line, but some may be given through the feeding tube. Some of the most common terms you will hear from the clinical team are:

• • Analgesics and sedatives: These medications help with pain control (analgesics) and will make your loved one sleepy (sedatives) and comfortable. There are many reasons why you may be uncomfortable in the ICU, such as the breathing tube, the intravenous lines, or simply discomfort from initial resuscitation efforts (i.e. chest pain or broken ribs from compressions) or anxiety or nervousness during awakening. These medications are given in the form of a drip (continuous medication given through an IV), fixed daily dosing, or only when necessary (PRN). If given continuously in a drip, the medical team will and should stop sedatives for some time in the morning to allow your loved one to wake up and obtain a more accurate neurological exam. A few examples of analgesics include Tylenol, Ibuprofen, Morphine, Hydromorphone, and Fentanyl. Sedatives commonly used are Propofol, Dexmedetomidine, and/or Midazolam.
• • Anticoagulants or blood thinners: Blood thinners may be given in the ICU for multiple reasons. Your loved one’s cardiac arrest must have been caused by a heart attack and thus, they need to be on a blood thinner. Small doses of blood thinner injections are given routinely 2-3 times daily to prevent blood clots in legs or arms (called deep venous thrombosis or “DVT”), as being immobile in bed can cause these blood clots to form. The most common blood thinners are heparin or enoxaparin.
• • Insulin: Insulin is given as an injection or intravenously, and there is a good chance your loved one may require insulin temporarily as acute diseases in the ICU tend to raise the blood sugar.
• • Fluids: IV fluids are given to keep the body hydrated and prevent unwanted effects of dehydration such as increased heart rate, decreased blood pressure, lightheadedness, or kidney damage.
  • Delirium medications: Your loved one may become confused during the later part of their ICU stay, particularly after regaining consciousness. They can also become agitated and have disrupted sleep patterns. This is normal and expected during the ICU stay as multiple providers come in and out of the room during all hours of the day in addition to the hourly nursing checks, disrupting the  internal sleep clock. The clinical team may start medications such as Melatonin, Quetiapine, Olanzapine, or Risperidone to keep them calm. 
• • Vasopressors: There may be a temporary need for medications to raise blood pressure if it is too low. These medications are called vasopressors and are usually given through a central line and occasionally through peripheral IV. Some examples of vasopressors are vasopressin, epinephrine, and norepinephrine.
• • Paralytics: Medications to paralyze the muscles may be used when someone is undergoing cooling treatment with the goal of suppressing shivering or when the lungs are not functioning well and are fighting with the ventilator machine to maintain acceptable oxygen levels. Your loved one will also be receiving sedating and analgesic medications to reduce any anxiety about being paralyzed.
• • Stomach acid-reducing medications: The stomach lining can become irritated while someone is intubated, so the medical team starts medications to reduce the stomach acid and prevent ulcers that can bleed. Examples of these medications are omeprazole, famotidine, and pantoprazole.
• • Bowel regimen: Since there will not be much movement when your loved one is in the ICU, bowel movements may not be regular. The medical team will start medications to help maintain regular bowel movements. Some examples are Docusate, Senna, and Miralax.

Sources

Understanding Your ICU Stay: https://www.sccm.org/getattachment/MyICUCare/During-the-ICU/UNDERSTAND_Download.pdf?lang=en-US

Your Time in the Intensive Care Unit: https://icusteps.org/information/guide-to-intensive-care/your-time-in-the-icu

Thank you to our contributors

Samantha Fernandez & Sachin Agarwal