Yearbook of Intensive Care and Emergency Medicine 2008 (eBook)

Table of Contents 5
List of Contributors 11
Common Abbreviations 27
I Genetic Factors 28
Are Pharmacogenetics and Pharmacogenomics Important for Critically Ill Patients? 29
Introduction 29
Pharmacogenetics or Pharmacogenomics? 29
Pharmacogenetics, Pharmacogenomics, and Drug Metabolism 30
Clinically Relevant Genetic Polymorphisms in Critical Care 31
Population Variations in Pharmacogenetics (Table 2) 34
Challenges to Implementing Pharmacogenetics in Critically Ill Patients 35
Conclusion 36
References 36
Genetic Susceptibility in ALI/ARDS: What have we Learned? 39
Introduction 39
Basic Principles of Genomic Association Studies Related to Critical Care Syndromes 40
Limitations of Genomic Association Studies Related to Critical Care Syndromes 43
Future Considerations in Genomic Association Studies Related to Critical Care Syndromes 45
Conclusion 47
References 47
Racial Disparities in Infection and Sepsis: Does Biology Matter? 50
Introduction 50
What is Race? 50
Differences in Disease Susceptibility 51
Differences in Access to Health Care 51
Differences in Quality of Care 52
Could Differences in Underlying Biology Contribute to Racial Disparities? 53
Conceptual Model of Racial Disparities 54
Design Challenges for Further Studies 55
Conclusion 55
References 55
II Cardiac Issues 57
B-Type Natriuretic Peptide: An Emerging Biomarker in Pediatric Critical Care 58
Introduction 58
Natriuretic Hormone System 59
B-Type Natriuretic Peptide 59
BNP in Adult Cardiac Disease 60
BNP in Pediatric Cardiac Disease 61
BNP as a Biomarker Following Cardiac Surgery 62
Respiratory Distress: Differentiating between Potential Etiologies 63
Patent Ductus Arteriosus 64
BNP in Other Pediatric Illnesses 64
Exogenous Administration of BNP 64
Conclusion 65
References 65
Cardiac Dysfunction in Septic Shock 68
Introduction 68
Mechanisms Leading to Cardiac Dysfunction in Sepsis 68
Systolic and Diastolic Cardiac Dysfunction in Sepsis 72
Beta-adrenergic Hyporesponsiveness and Hibernation in Septic Shock 75
Lactate: the New Fuel 76
Conclusion 76
References 77
The Consequences of Cardiac Autonomic Dysfunction in Multiple Organ Dysfunction Syndrome 80
Link between Autonomic Dysfunction and Inflammation: The ‘Cholinergic Anti-inflammatory Pathway’ 80
Heart Rate ‘Stiffness’ as a Measure of Cardiac Autonomic Dysfunction in Patients with MODS: Possible Mechanisms 83
Can We Increase the Depressed Vagal Activity in Patients with MODS and, Thereby, Improve Prognosis? 85
Conclusion 88
References 88
Quantification of Improved Left Ventricular Performance during Cardiac Resynchronization Therapy 90
Introduction 90
Conceptual Framework 90
Clinical Applications of Left Ventricular Dyssynchrony Quantification 91
Modeling Contraction Dyssynchrony 94
Human Data 97
Conclusion 98
References 98
Diastolic Dysfunction and Cardiac Failure in the Intensive Care Unit 101
Introduction 101
Definitions 101
Diastolic Dysfunction 104
Conclusion 111
References 111
Pharmacological Support of the Failing Right Ventricle 113
Introduction 113
Pathophysiology of Right Ventricular Failure 113
Therapeutic Options 114
Conclusion 122
References 122
Perioperative Cardioprotection 126
Introduction 126
Preoperative Coronary Revascularization 126
Pharmacological Cardioprotection 128
Miscellaneous Preventive Measures 133
Conclusion 133
References 133
III Cardiopulmonary Resuscitation 136
Improving the Quality of Cardiac Arrest Resuscitation Care 137
Introduction 137
Improving Bystander Cardiopulmonary Resuscitation 138
Device Adjuncts to Manual Cardiopulmonary Resuscitation 139
Mechanical Cardiopulmonary Resuscitation Devices 140
Training and Education 140
Other Cardiopulmonary Resuscitation Techniques 142
Conclusion 142
References 143
Pediatric Cardiopulmonary Arrest and Resuscitation 145
Introduction 145
Epidemiology of Pediatric Cardiac Arrest 145
Mechanism of Blood Flow to Vital Organs during Cardiac Arrest 148
Interventions during Cardiac Arrest (No-Flow) and CPR (Low Flow) Phases 150
Post-resuscitation Interventions 152
Post-resuscitation Outcomes and Quality of Life 153
Special Resuscitation Circumstances 153
Quality of CPR and Resuscitation Interventions 155
Special Issues in Simulation, Advanced Education, and Implementation of Programs 156
Future Directions and Potential Obstacles 156
Conclusion 157
References 157
Early Cooling in Cardiac Arrest: What is the Evidence? 161
Introduction 161
Pathophysiology 161
“Is sooner better”? 162
Human Data about Pre-hospital Hypothermia 163
Conclusion 165
References 166
IV Emergencies 169
Management of Severe Accidental Hypothermia 170
Introduction 170
Definitions 170
Pathophysiology 170
Consequences of Hypothermia in Trauma Patients 171
Etiological Classification of Hypothermia 172
Pre-Hospital Care (Fig. 1) 172
Resuscitation Guidelines According to Clinical Staging of Hypothermia 174
Conclusion 180
References 180
Initial ICU Management of Skin Sloughing Diseases: Toxic Epidermal Necrolysis and Stevens-Johnson Syndrome 183
Introduction 183
Toxic Epidermal Necrolysis 183
Conclusion 189
References 189
V Poisonings 191
Pathophysiology of Caustic Ingestion 192
Introduction 192
Factors Affecting the Extent and Severity of Gastrointestinal Injury due to Caustic Ingestion (Fig. 1). 192
Site of Gastrointestinal Injury following Caustic Ingestion 197
Changes in the Esophagus after Caustic Ingestion 197
Conclusion 197
References 198
Extracorporeal Life-Support for Acute Drug-induced Cardiac Toxicity 200
Introduction 200
Features of Drug-induced Cardiac Toxicity 201
Mechanisms of Drug-induced Cardiac Toxicity 202
How to Optimize Conventional Management of Drug-induced Cardiac Toxicity 202
Extracorporeal Life Support for the Poisoned Failing Heart 206
Extracorporeal Life Support Management for Acute Poisonings in the Medical ICU 208
Conclusion 209
References 209
VI Acute Respiratory Failure 211
Epidemiology of Acute Respiratory Failure and Mechanical Ventilation 212
Introduction 212
Definition and Classification 212
Incidence and Outcome of Acute Respiratory Failure 213
Epidemiology of Specific Clinical Syndromes 215
Conclusion and Future Considerations 219
References 220
Esophagectomy and Acute Lung Injury 222
Introduction 222
Esophagectomy 222
Acute Lung Injury/Acute Respiratory Distress Syndrome 223
Incidence and Outcome of ALI/ARDS following Esophagectomy 224
Risk Factors for the Development of ALI/ARDS 225
The Nature of ALI/ARDS following Esophagectomy 227
Prevention and Treatment Options for ALI/ARDS after Esophagectomy 229
Conclusion 230
References 230
Glucocorticoid Treatment in Acute Respiratory Distress Syndrome: Friend or Foe? 233
Introduction 233
ARDS: A Static or Progressive Disease? 233
Mechanisms of Action of Corticosteroids 234
What Recent Animal Research has Taught Us about Corticosteroids 236
Prospective Randomized Trials on Corticosteroids in ARDS 236
Conclusion 239
References 240
Regional Lung Function in Critically Ill Neonates: A New Perspective for Electrical Impedance Tomography 243
Introduction 243
Measuring Principle of EIT 244
Regional Lung Ventilation in Preterm and Term Neonates with no Lung Pathology 245
Regional Lung Ventilation during Mechanical Ventilation in Infants with Lung Disease 247
Conclusion 251
References 252
Extracorporeal Lung Assist for Acute Respiratory Distress Syndrome: Past, Present and Future 254
Introduction 254
Clinical History of Extracorporeal Lung Assist 255
Further Development of Extracorporeal Lung Assist 256
Veno-venous Extracorporeal Membrane Oxygenation Today 257
Arterio-venous Pumpless Interventional Lung Assist 258
Future Development of ECLA 259
Conclusion 260
References 260
VII Ventilatory Support 262
Protective Mechanical Ventilation: Lessons Learned From Alveolar Mechanics 263
Introduction 263
Chapter Overview 263
Acute Respiratory Distress Syndrome 264
Alveolar Mechanics 264
Mechanisms of VILI at the Alveolar Level 267
Protective Mechanical Ventilation and Alveolar Mechanics 269
PEEP, Low Tidal Volumes, and Alveolar Mechanics 269
Open Lung Approach and Alveolar Mechanics 270
HFOV, APRV, and Alveolar Mechanics 270
Conclusion 271
References 271
Mechanical Ventilation for Acute Asthma Exacerbations 274
Introduction 274
Pathophysiology of Acute Severe Asthma 274
Mechanical Ventilation 277
Alternative Therapies 283
Conclusion 284
References 285
Hypercapnia: Permissive, Therapeutic, or Not at All? 287
Introduction 287
Physiological Effects of Hypercapnia 288
Insights from Laboratory Studies 290
Cellular and Molecular Effects of Hypercapnia 291
Current Clinical Role of Permissive Hypercapnia 292
Hypercapnia: Balancing Risk and Benefit 295
Conclusion 296
References 297
The Cardiopulmonary Effects of Hypercapnia 300
Introduction 300
Hypercapnia and Lung Injury 301
Hypercapnia and Lung Clearance 302
Hypercapnia and the Heart 302
Hemodynamic Effects of Hypercapnia 303
Conclusion 304
References 305
High Frequency Oscillation for Acute Respiratory Failure in Adults 308
Introduction 308
Mechanisms of Gas Transport and Exchange 308
Mechanics of Ventilation and HFOV settings 311
Evidence Supporting the Clinical Use of HFOV VII 313
Complications during HFOV 314
Adjuncts to HFOV 315
Conclusion 315
References 316
Airway Pressure Release Ventilation: Promises and Potentials for Concern 319
Introduction 319
Ventilator-Associated Lung Injury (VALI) 319
ARDS: Clinical Experience 321
Airway Pressure Release Ventilation: The Basics 321
Indications and Settings of APRV for Practical Use 322
Airway Pressure Release Ventilation: Clinical Data, Advantages, Disadvantages 324
Conclusion 325
References 325
Postoperative Non-invasive Ventilation 328
Introduction 328
Epidemiology 331
Surgery-induced Respiratory Modifications and Rationale for Postoperative NIV Use 331
Results 332
Setting, Specificities, and Limits of Postoperative NIV 334
Conclusion 335
References 335
VIII Tracheostomy 338
Choice of Tracheostomy Tube: Does One Size Fit All? 339
Introduction 339
Historical Perspective 339
Relevant Anatomy and Pathophysiology 340
Tube Design Considerations 341
Assessment of Tube Size and Position 345
Conclusion 345
References 345
What’s new in Percutaneous Dilational Tracheostomy? 347
Introduction 347
Percutaneous Dilational Tracheostomy: A Risky Procedure? 347
Percutaneous Dilational Tracheostomy or Conventional Tracheostomy 347
When to Perform Percutaneous Dilational Tracheostomy? 348
Patient Selection for Percutaneous Dilational Tracheostomy 348
Are Chest X-rays Necessary Afterwards? 352
Posterior Tracheal Wall Injury 352
Long-term Outcome after Percutaneous Dilational Tracheostomy 354
Conclusion 354
References 354
IX Infections 357
Novel Therapies in the Prevention of Ventilator-associated Pneumonia 358
Introduction 358
Is it Worth Investment in Novel Strategies? 359
Novel Strategies 360
Conclusion 364
References 365
Management of Ventilator-associated Pneumonia 368
Introduction 368
Epidemiology 368
Pathogenesis 370
Diagnosis 372
Treatment 375
Conclusion 377
References 377
Flucytosine Combined with Amphotericin B for Fungal Infections: A Postmarketing Surveillance and Future Perspectives 380
Introduction 380
Postmarketing Surveillance on Efficacy and Safety 380
Efficacy of Flucytosine and Amphotericin B Treatment 382
Side Effects of Flucytosine and Amphotericin on Renal and Hepatic Function 383
Flucytosine and Amphotericin B in Candida Peritonitis 384
Flucytosine and Amphotericin B in Meningeal Disease 385
Effectiveness of Flucytosine and Amphotericin B in Critically Ill Patients 385
Future Perspectives on the Combination of Flucytosine and Amphotericin B 385
Conclusion 386
References 386
X Cellular Mechanisms in Sepsis 388
Apoptosis in Critical Illness: A Primer for the Intensivist 389
Introduction 389
Cellular Mechanisms of Apoptosis 389
Therapeutic Implications 395
Conclusion 396
Regulation of Mitochondrial Function by Hypoxia and Inflammation in Sepsis: A Putative Role for Hypoxia Inducible Factor 399
Introduction 399
The Mitochondrion: The Powerhouse of the Cell 399
Electron Transport Chain 401
Measurement of Mitochondrial Oxygen Consumption 402
Hypoxia Inducible Factor-1 L 404
HIF and Mitochondrial Respiration during Hypoxia 405
Endotoxin and Mitochondrial Function 405
HIF and Inflammation 406
References 407
Gram-positive and Gram-negative Sepsis: Two Disease Entities? 409
Introduction 409
Bacterial Components and the Origins of Sepsis 410
Toll-like Receptors and Cell Signaling in Systemic Inflammation 410
Cytokines and Systemic Inflammation 412
Differences between Gram-positive and Gram-negative Sepsis Identified in Clinical Trials 413
Clinical Differences in Gram-positive and Gram-negative Sepsis 413
Genetic Predisposition 414
Therapeutic Implications of TLRs 415
Conclusion 415
References 415
Methicillin-resistant Staphylococcus aureus-induced Sepsis: Role of Nitric Oxide 418
Introduction 418
Epidemiology of MRSA Infections 418
Pathophysiology of MRSA-induced Pneumonia/sepsis 419
Conclusion 422
References 423
XI Sepsis Therapies 425
The Cardiovascular Management of Sepsis 426
Introduction 426
Cardiovascular Changes due to Sepsis 426
The Management of Septic Shock 427
Conclusion 433
References 433
Terlipressin in Septic Shock: When and How Much? 436
Introduction 436
Pharmacokinetic Aspects of Terlipressin 437
Pharmacodynamics of Terlipressin Relevant to the Treatment of Septic Shock 437
Rationale for the Use of Terlipressin in Shock States 438
Experimental Evidence for the Use of Terlipressin 439
Clinical Evidence for the Use of Terlipressin 441
Limiting Adverse Effects: Less May Be Best 443
View into the Future 444
Summary and Conclusion 444
References 445
Blood Purification Techniques in Sepsis and SIRS 447
Introduction 447
Three New Theories of Blood Purification 447
Blood Purification Techniques Available in 2008 449
Which Technique is Best: Increasing Volume or Increasing Porosity? 450
Which Mode of Renal Replacement Therapy and which Dose is Superior? 451
The Concept of ‘Immunoparalysis’ and ‘Prophylactic’ Hemofiltration 452
Mediator Removal is Obsolete as Many Pathways are Involved in a ‘Pleiotropic’ Approach 453
Clinical Implications and Conclusion 454
References 454
Glutathione in Sepsis and Multiple Organ Failure 457
Introduction 457
Glutathione Metabolism 457
Effects of Glutamine Supplementation on Glutathione in Muscle 458
Temporal Pattern of Muscle Glutathione in ICU Patients 460
Temporal Pattern of Blood Glutathione in ICU Patients 461
Glutathione Status following Endotoxin Administration 462
Discussion 463
Conclusion 464
References 465
Selenocompounds and Selenium: A Biochemical Approach to Sepsis 467
Introduction 467
Oxygen: Oxidation, Reactive Oxygen Species, and Redox-potential 467
Biological Importance of Selenium 469
Selenocompounds as Prooxidants 471
Selenium Administration in Nutrition and in ICU Patients 474
Conclusion 479
References 479
XII Metabolic Alterations 483
The Role of Hypoxia and Inflammation in the Expression and Regulation of Proteins Regulating Iron Metabolism 484
Introduction 484
Iron Homeostasis 484
Hypoxia-Inducible Factor (HIF-1 ): A Link between Iron and Oxygen? 487
Clinical Potential 489
Challenges/Perspectives/Summary 489
References 490
Hyperammonemia in the Adult Critical Care Setting 492
Introduction 492
Causes of Hyperammonemia 492
Pathophysiology of Hyperammonemia 493
Symptoms of Hyperammonemia 495
Diagnosis of Hyperammonemia 497
Treatment of Hyperammonemia 497
Conclusion 500
References 500
Magnesium in the ICU: Sine qua non 502
Introduction 502
Magnesium Physiology and Clinical Aspects 503
Metabolism of Magnesium 503
Assessment of Magnesium Status 504
Magnesium in Analgesia and Sedation 505
Neuroprotective Effects of Magnesium 506
Magnesium and Sepsis 508
Conclusion 509
References 510
Strict Glycemic Control: Not If and When, but Who and How? 513
Introduction 513
Search Criteria 513
What is Being Advised: Opinions and Recommendations 514
What is Said to be Performed: Surveys On Strict Glycemic Control 517
What Is Performed: Studies on Experiences with Strict Glycemic Control 518
Discussion 518
Conclusion 521
References 522
Cortisol Metabolism in Inflammation and Sepsis 525
Introduction 525
Brief Review of Physiology 525
Modulation of Tissue Cortisol Concentrations 526
Mechanisms of HSD Activation in Inflammation and Sepsis 528
Implications and Conclusion 529
References 529
XIII Fluid Management 531
Assessment of Perioperative Fluid Balance 532
Introduction 532
Physical Examination and Routine Monitoring 533
Advanced Hemodynamic Monitoring 533
Laboratory Evaluation 540
Conclusion 543
References 543
Fluid Resuscitation and Intra-abdominal Hypertension 545
Introduction 545
Why do we like Fluids? 545
Which Fluids do we Like? 546
Do we like Fluids too Much? 547
So, How Should We Use Fluids? 550
If My Patient Develops Secondary ACS, How do I clear the Fluid excess? 552
Conclusion 555
References 555
XIV Acute Kidney Injury 558
Six Truths about Acute Kidney Injury that the Intensivist Should Be Aware Of 559
Introduction 559
Truth No. 1: AKI Kills Patients 560
Truth No. 2: The Incidence of AKI is High and Increasing 560
Truth No. 3: Diuretics Offer no Survival Benefit in the Treatment of AKI 561
Truth No. 4: Renal Dose Dopamine Should Not Be Used 562
Truth No. 5: Prevention of Contrast-induced Nephropathy: Volume Matters 562
Truth No. 6: Continuous Renal Replacement Therapy Offers No Survival Benefit over Intermittent Renal Replacement Therapy (Yet!) 564
Conclusion 564
References 564
Role of Poly(ADP-Ribose) Polymerase in Acute Kidney Injury 567
PARP-1 567
PARP-1 in Acute Kidney Injury 569
Potential Future Clinical Applications 573
Conclusion 574
References 574
From Hemodynamics To Proteomics: Unraveling the Complexity of Acute Kidney Injury in Sepsis 576
Introduction 576
Kidney Hemodynamics in Sepsis: A Challenging Concept 576
Renal Microcirculation: A Culprit in Acute Kidney Injury 578
From Hemodynamics to Proteomics: Sepsis and Acute Kidney Injury from a Molecular Perspective 579
Conclusion 583
References 584
XV Hemodynamic Assessment and Management 587
Towards Optimal Central Venous Catheter Tip Position 588
Introduction 588
Optimal Position for Catheter Tip 588
Complications Related to CVC misplacement 589
Methods to Determine CVC Tip Position 592
Conclusion 595
References 595
From Arterial Pressure to Cardiac Output 598
Introduction 598
Background 598
From Bench to Bedside 602
Conclusion 606
References 607
Hemodynamic Monitoring: Requirements of Less Invasive Intensive Care – Quality and Safety 609
Introduction: Some Definitions 609
Historical Outline 609
The Requirements for Quality Monitoring 611
So, Which Tool? 612
Conclusion 612
References 613
Minimally Invasive Cardiac Output Monitoring: Toy Or Tool? 614
Introduction 614
Pulse Wave Analysis 615
Conclusion 621
References 623
Bioreactance: A New Method for Non-invasive Cardiac Output Monitoring 626
Introduction 626
What Is Bioreactance? 627
What Is Bioreactance? 627
From Chest Bioreactance to Cardiac Output 630
Experimental Validation 632
Clinical Validation 633
Limitations 635
Conclusion 636
References 636
Goal-directed Hemodynamic Therapy for Surgical Patients 638
Introduction 638
Epidemiology 638
Identification of the High-risk Patient 638
The Process of Goal-directed Hemodynamic Therapy 640
Intraoperative Goal-directed Therapy 640
Postoperative Goal-directed Therapy 641
Future Advances 642
Conclusion 642
References 643
XVI Tissue Oxygenation 645
Use of Mixed Venous Oxygen Saturation in ICU Patients 646
Introduction 646
Physiology 646
SvO2 Measurement 650
The Current Place of SvO2 in Clinical Practice 652
Conclusion 656
References 656
Early Optimization of Oxygen Delivery in High-risk Surgical Patients 659
Introduction 659
Why Early Goal-directed Therapy for Certain Surgical Patients? 659
Assessment of Fluid Status and Fluid Challenge: Important Concepts during Goal-directed Therapy 660
How to Decrease Mortality? 661
Can Goal-directed Therapy be Performed in High-Risk Patients with Fluids Alone or is Inotropic Support Necessary? 662
Goal-directed Therapy: Necessity or Futility? 663
Is a Minimally Invasive Technique Suitable for Intraoperative Optimization Therapy? 664
Who is the High-risk Patient Likely to Benefit From Goal-directed Therapy? 666
Conclusion 667
References 667
The Influence of Packed Red Blood Cell Transfusion on Tissue Oxygenation 670
Introduction: Indications for Perioperative Transfusions – The Physiologic Transfusion Trigger for Red Blood Cells 670
Physiology of Oxygen Transport 671
The Concept of Critical Oxygen Delivery/Critical Hb Level 672
Measuring Tissue Oxygenation and Microcirculatory Flow 673
Effect of RBC Transfusion on Tissue Oxygenation in Experimental and Clinical Studies 677
Conclusion 679
References 679
Recent Advancements in Microcirculatory Image Acquisition and Analysis 682
Introduction 682
Sidestream Dark Field (SDF) Imaging 683
Automated Image Analysis 685
Consensus on Microcirculatory Image Acquisition and Analysis 686
Microcirculatory Glycocalyx Thickness Measurement 689
Microcirculatory Imaging in Conjunction with Tissue Capnography 690
Future Directions 692
Conclusion 693
References 693
The Beneficial Effects of Increasing Blood Viscosity 696
Introduction 696
The Link between Blood Viscosity and Nitric Oxide 696
Blood Viscosity, Hemodilution, and Microvascular Function 697
Elevated Plasma Viscosity 698
Blood Rheology and Hemodilution 698
Viscogenic Plasma Expanders 699
Resuscitation from Hemorrhagic Shock 700
The Role of RBC-related Oxygen Carrying Capacity in Hemorrhage Resuscitation 702
Conclusion 703
References 703
XVII Anticoagulants in Organ Failure 706
Protein C and Antithrombin Levels in Surgical and Septic Patients 707
Introduction 707
Blood Coagulation: The Basic Science 707
Protein C Pathway 708
Interactions between Coagulation and Inflammation 709
Protein C and Antithrombin Levels in Surgical ICU Patients 710
Prognostic Value of Protein C and Antithrombin Levels 712
Protein C and Antithrombin Deficiency: Clinical Implications 713
Conclusion 715
References 715
Thrombophilia as a Risk Factor for Outcome in Sepsis 717
Introduction 717
Sepsis and Coagulation 717
Coagulation Factor Gene Polymorphisms and Outcome in Infection and Sepsis 718
Genetic Variation in the Protein C and Antithrombin Pathways and Outcome in Infection and Sepsis 718
Factor V Leiden and Sepsis 720
Gene Polymorphisms in the Fibrinolytic System and Outcome in Infection and Sepsis 721
Conclusion 722
References 722
The Effects of Activated Protein C on the Septic Endothelium 725
Introduction 725
Protein C Pathway 726
Anticoagulant Protein C Pathway 727
Cytoprotective Protein C Pathway 727
APC-related Endothelial Cell Gene Expression Alteration and Anti-inflammatory Activity 728
Anti-apoptotic Activity 728
Endothelial Cell Barrier Stabilization 729
APC in Acute Lung Injury 729
APC Variants 731
Conclusion 732
References 732
Improvement in Hemodynamics by Activated Protein C in Septic Shock 734
Introduction 734
What is the Clinical Evidence for the Hemodynamic Effects of rhAPC? 734
Animal Studies and Underlying Mechanisms 736
Conclusion 739
References 739
XVIII Acute Bleeding 741
Gastrointestinal Hemorrhage on the Intensive Care Unit 742
Introduction 742
Stress-related Mucosal Disease 742
Variceal Hemorrhage 748
Lower Gastrointestinal Bleeding 750
Conclusion 751
References 751
Recombinant Activated Factor VII: The Delicate Balance between Efficacy and Safety 754
Introduction 754
Efficacy in Prophylaxis Trials 754
Efficacy in Curative Trials 756
Safety: Thrombo-embolic Complications 758
Safety Profile: Volunteers and Licensed Indications 758
Safety Profile: Off-label Indications 759
Conclusion 760
References 761
XIX Hepatic Disease 763
ICU Management of the Liver Transplant Patient 764
Introduction 764
Early Extubation and Non-invasive Ventilation 764
Hemodynamic Management 766
Splanchnic Perfusion and Graft Function 768
Fluid Management and Transfusion 769
Lung and Liver Function 770
Renal Function 771
Neurological Status and Sedation in the ICU 774
Conclusion 775
References 775
Liver Support with Fractionated Plasma Separation and Adsorption and Prometheus® 778
Introduction 778
The Concept of Albumin Dialysis 778
FPSA and the Prometheus® System 779
How to Prescribe the Prometheus® Therapy 779
Who should be treated with Prometheus®? 781
Contraindications for Prometheus® Treatment 783
Conclusion 784
References 784
Artificial Liver Support: Current Status 786
Introduction 786
Early Liver Support Devices Based on Hemodialysis, Hemadsorption, Blood and Plasma Exchange 786
Artificial Devices Using Albumin Dialysis 789
Artificial Liver Devices and Cytokines 794
Conclusion 796
References 796
XX Neurological Crises 800
Encephalopathy in Sepsis 801
Introduction – Definition 801
Pathophysiology of Sepsis-associated Delirium 801
Diagnosis of Sepsis-associated Encephalopathy 804
Investigations in Sepsis-associated Encephalopathy 806
Risk Factors and Outcome 807
Treatment of Sepsis-associated Encephalopathy 807
Conclusion 808
References 808
Multimodality Monitoring in Patients with Elevated Intracranial Pressure 811
Introduction 811
CPP is the Most Important Hemodynamic Parameter to Consider in the Treatment of Elevated ICP 811
The ICP Waveform is a Reflection of Intracranial Compliance 813
Lundberg A (Plateau) Waves Require Treatment with CPP Augmentation 814
Jugular Venous Oxygen Saturation is a Measure of the Adequacy of Cerebral Blood Flow and Cerebral Metabolic Activity 814
Brain Tissue Oxygen Tension Reflects Local Brain Oxygen Supply and Demand in the Region of Catheter Placement 815
Microdialysis Technology Allows For Direct Evaluation of the Cerebral Biochemical Environment 817
Continuous Electroencephalography Detects Subclinical Seizure Activity and Reveals Changes in Regional Brain Metabolic Activity in Real Time 818
Transcranial Doppler Ultrasound Allows for Bedside Assessment of Intracranial Pressure, Vascular Tone, Blood Flow, and Autoregulatory Reserves 818
Putting it all Together: Advanced Neuromonitoring Allows Clinicians to Identify and Respond to Events in the Brain Before Irreversible Damage Occurs 819
References 820
Managing Critically Ill Patients with Status Epilepticus 822
Introduction 822
Diagnosis of Status Epilepticus 822
Differential Diagnoses 824
Advances in the Treatment of Status Epilepticus 825
Treatment Strategies 828
Conclusion 834
References 834
XXI Analgesia and Sedation 837
Sedation with Inhaled Anesthetics in Intensive Care 838
Introduction 838
Sedation using Inhalational Anesthetics 839
How to Administer Inhalation Anesthetics in the ICU: The Anaconda Device 840
Setting up the ACD in Clinical Practice 841
Selecting the Anesthetic Agent for use with the ACD 842
Selecting the Anesthetic Concentration and Co-adjuvant Therapy 843
Adjusting the Syringe Pump-rate with the ACD 843
Conclusion 845
References 846
Sedation or Analgo-sedation in the ICU: A Multimodality Approach 849
Introduction 849
Drugs 850
Multimodality in Terms of “Balanced Sedation” 852
Current Problems in Sedation Regimens 855
Management of Sedation 856
Drug Tolerance and Narcotic-induced Hyperalgesia and Withdrawal 857
Discussion 858
Conclusion 860
References 860
XXII Outcomes 862
Time to Use Computerized Physician Order Entry in all ICUs? 863
Introduction 863
Medication Errors and Adverse Drug Events 863
Computerized Physician Order Entry to the Rescue! 865
CPOE in Practice 870
Conclusion 876
References 876
Quality of Life in Locked-in Syndrome Survivors 879
Introduction 879
Definition, Etiology and (mis)Diagnosis 880
Prognosis and Quality of Life 881
End-of-life Decisions 883
Cognitive Functioning and Communication 884
Conclusion 887
References 887
Post-traumatic Stress Disorder in Intensive Care Unit Survivors 889
Introduction 889
A Brief Background of Post-traumatic Stress Disorder and its Diagnosis 889
ICU Treatment as a Traumatic Stressor 891
Methodologies of Studies of ICU-related Post-traumatic Stress Disorder 891
Reported Prevalence of Post-traumatic Stress Disorder and Post-traumatic Symptomatology 892
Limitations of Existing Studies 895
Risk Factors for ICU-related Post-traumatic Stress Disorder 898
Conclusion 900
References 901
Subject Index 904