Intensive care and critical care: how is the pathway of a seriously ill patient organised?

What distinguishes intensive care from a standard hospital stay?

Intensive care admits patients in whom one or more vital functions are threatened or require very close monitoring. The teams can support breathing, circulation, the kidneys or other organs while the cause is treated. Not all the equipment visible around the patient is “life support”: some of it monitors, some delivers medicines and some temporarily replaces a function.

Stabilising vital functions

On admission, the team assesses breathing, circulation, neurological status, infection, pain and organ function. Tests are prioritised according to urgency. Treatment of the cause is sought at the same time as organ support: antibiotics and source control in sepsis, treatment of bleeding, and cardiac, neurological or surgical care depending on the situation.

Ventilation, sedation and waking up

Mechanical ventilation may be necessary when the patient cannot breathe adequately on their own. A tube may be placed in the windpipe and connected to a ventilator. Painkillers and sedatives are often necessary, but modern practice seeks to adapt sedation to need and to assess regularly whether the patient can be woken or breathe more independently.

The Society of Critical Care Medicine’s ICU Liberation programme brings together, as a set of measures (the “ICU Liberation Bundle”), practices based on the PADIS guidelines: pain, spontaneous awakening and breathing trials, choice of sedatives, prevention and management of delirium, early mobilisation and family involvement.

Why might a patient be confused?

Delirium is an acute, fluctuating state of confusion that is common in intensive care. It can be promoted by serious illness, infection, certain medicines, lack of sleep, age or the environment. It does not necessarily mean that permanent brain damage has occurred. Orientation, sleep, glasses/hearing aids, mobilisation and appropriate sedation are part of the preventive measures.

The devices the family may see

Venous catheters, an arterial line, a urinary catheter, drains, a gastric tube and syringe pumps may be used depending on the situation. Each device must meet a specific need and be removed as soon as it is no longer necessary in order to limit complications.

Monitoring tracks the parameters needed for decisions, with individualised targets: a single figure does not replace the overall assessment. Infection prevention, early mobilisation when possible, nutrition, prevention of thromboembolic disease and skin care are part of daily care.

After intensive care

Recovery can continue long after the acute illness is under control. Muscle weakness, fatigue, sleep problems, anxiety, memory difficulties or post-traumatic stress may occur; this is sometimes called post-intensive care syndrome. Rehabilitation and follow-up are therefore important parts of the pathway.

Informing the family and making shared decisions

The family needs regular, understandable and consistent information. When complex choices have to be made, the patient’s values and goals must be taken into account. Guidelines on family-centred care encourage structured communication and appropriate involvement of the family.

Questions for the family

• Which organ currently needs support?
• What is the goal for the next 24 hours?
• Which medicines or devices are essential today?
• How can the family take part without getting in the way of care?

Frequently asked questions