Yearbook of Intensive Care and Emergency Medicine 2009 (eBook)

Table of Contents 5
List of Contributors 11
Common Abbreviations 28
I Genomics and Proteomics 29
Rethinking Sepsis: New Insights from Gene Expression Profiling Studies 30
Introduction 30
How to Identify and Measure Heterogeneity 30
Sources of Heterogeneity in Sepsis Patients 31
New Insights from Gene-expression Studies 32
Genomic Heterogeneity 34
Further Questions on an Existing Sepsis Model 36
Functional Mapping of Sepsis Genome to Monitor Immune Function 37
Conclusion 39
References 39
Mitochondrial Genetics and Sepsis 41
Introduction 41
Oxidative Phosphorylation and ATP Generation 41
Reactive Oxygen Species 42
Apoptosis 42
Mitochondria and Sepsis 43
Mitochondrial Genetics 43
Mitochondrial Haplogroups 44
Conclusion 47
References 47
Lung Proteomics in Intensive Care 50
Introduction 50
The Search for Biomarkers 50
Lung Proteomics 52
Applications in ALI/ARDS 58
Future Directions 59
References 62
II Inflammatory Response 64
The Host Response to Sepsis 65
Introduction 65
Epidemiology and Genetic Variability 66
Pathogen Recognition Systems 67
Coagulation and Anticoagulation 70
Immune Suppression and Apoptosis 72
HMGB1 and RAGE 72
The Cholinergic Anti-inflammatory Pathway 73
Macrophage Migration Inhibitory Factor 74
C5a and C5a Receptor 74
Conclusion 74
References 74
Endotoxin Tolerance: Mechanisms and Clinical Applicability 77
Introduction 77
Mechanisms of Endotoxin Tolerance 77
Endothelial Function and Microcirculation during LPS Tolerance 79
Clinical Applicability and Therapeutic Possibilities 81
Conclusions 82
References 82
Oxidative Stress and Endothelial Dysfunction during Sepsis 85
Introduction 85
Sources and Actions of ROS and RNS in the Endothelium during Sepsis 85
Mechanisms of Endothelial Dysfunction during Sepsis 87
Conclusion 89
References 90
Measurement of Carbon Monoxide: From Bench to Bedside 91
Introduction 91
Carbon Monoxide Measurement 91
Carbon Monoxide Concentrations in Critically Ill Patients 92
Carbon Monoxide Concentrations and Lung Diseases 96
Carbon Monoxide Concentrations and Other Diseases 103
Conclusion 103
References 103
Monitoring Immune Dysfunction in Septic Patients: Toward Tailored Immunotherapy 107
Introduction 107
Monocyte Dysfunction 108
T Lymphocyte Dysfunction 111
Conclusion 114
References 115
III Current and Future Management of Sepsis 117
Source Control in the ICU 118
Introduction 118
What is ‘Source Control’? 118
Elements of Source Control 119
Do we need to perform Source Control? 120
When to Perform Source Control? 121
The Role of the Intensivist 121
What if Source Control is Impossible or Fails? 123
Special Considerations in Critically Ill Patients 123
Conclusion 125
References 125
IgM-enriched Immunoglobulins in Sepsis 127
Introduction 127
Mechanisms of Action of IVIG in Sepsis 128
Differences between IgG- and IgM-enriched Immunoglobulins 129
Clinical Significance of IgM-enriched IVIG 130
Conclusion 133
References 134
Clarithromycin: A Promising Immunomodulator in Sepsis 136
Introduction 136
Indirect Evidence for an Immunomodulatory effect of Macrolides in Pneumonia 137
Lessons from Animal Studies 138
Conclusion 141
References 142
High-flow Hemofiltration as an Adjunctive Therapy in Sepsis 144
Introduction 144
Mechanism of Action: Hemofiltration as a New Shield against the ‘Chaos Theory’ and ‘Complex Non-linear Systems’ in Sepsis 144
Recent Animal Trials and Clinical studies Highlighting the Crucial Roles of Dosing and Timing 146
Practical Aspects for the Bedside Clinician 148
Future Directions Regarding the Use of Hemofiltration in Sepsis 149
Conclusion 150
References 151
Economic and Social Burden of Severe Sepsis 154
Introduction 154
Concepts 154
Direct Costs of Sepsis Management 156
Direct Costs of Sepsis Management in Developing Countries: A Brazilian Experience 157
Indirect Costs and Burden of Illness 158
Impact of Therapeutic Strategies on Costs 159
Conclusion 161
References 162
IV Proposed Targets for New Therapies 164
Lymphocyte Apoptosis in Sepsis and Potential Anti-apoptotic Strategies 165
Introduction 165
Mechanisms of Apoptosis 166
Pathways Involved in Apoptosis 166
Evidence in Animals 168
Evidence in Humans 170
Therapeutic Molecular Targets 171
Conclusion and Perspectives 172
References 172
The Pivotal Role of Beta-adrenoreceptors in Critical Illness Pathophysiology 175
Introduction 175
New Concepts in Adrenoreceptor Signaling Biology 175
Desensitization of Beta-adrenoreceptors 177
Catecholamine-induced Immune Dysregulation 178
Beta-adrenoreceptor-mediated Metabolic Effects of Critical Illness 180
Beta-adrenoreceptor-mediated Effects on Barrier Gut Function 181
Specific Beta-adrenoreceptor-mediated Roles in Common Critical Illness Pathophysiology 181
Limitations of Current Experimental/clinical Data 182
Conclusion 182
References 183
Non-septic Acute Lung Injury and Inflammation: Role of TLR4 186
Introduction 186
Participation of TLR4 in Ischemia-reperfusion Injury 186
Heme Activates TLR4 by Different Mechanisms than does LPS 187
Acute Lung Injury Produced by Avian Influenza Virus H5N1 or Acid Aspiration is Dependent on Activation of TLR4 By Oxidized Phospholipids 189
Fragmented Hyaluronic Acid activates TLR4 189
TLR4 Participates in Inflammation Associated with Ventilator-induced Lung Injury or Cardiac Hypertrophy Produced by Aortic Stenosis 189
TLR4 Participates in Late Inflammatory Responses in which HMGB1 Plays a Contributory Role 190
Heat Shock Proteins (HSP) Induce Pro-inflammatory Cytokine Release through TLR4 190
TLR4 Participates in Ethanol-induced Inflammation 191
Acetaminophen-induced Liver Injury is TLR4-dependent 191
Conclusion 192
References 192
Hydrogen Sulfide: A Metabolic Modulator and a Protective Agent in Animal Models of Reperfusion Injury 195
Introduction 195
The Biological Chemistry of Hydrogen Sulfide 195
H2S as an Inducer of a State Resembling Suspended Animation 196
Protective Effects of H2S in Local or Whole-body Ischemia or Ischemia-reperfusion 198
Conclusion 200
References 200
V Septic Shock 204
‘Myocardial Depression’ or ‘Septic Cardiomyopathy’? 205
Introduction 205
Septic Cardiomyopathy: A Secondary Cardiomyopathy in the Scope of the Systemic Disease, ‘Sepsis’ 205
How to Quantify Septic Cardiomyopathy? 208
Septic Cardiomyopathy is of Prognostic Relevance 209
Septic Cardiomyopathy: Triggers and Mechanisms 210
Causal Approaches towards the Treatment of Acute Septic Cardiomyopathy 213
Conclusion 214
References 214
Determinants of Tissue PCO2 in Shock and Sepsis: Relationship to the Microcirculation 217
Introduction 217
Mechanisms of Increase in Venous and Tissue PCO2: The Basics 217
Intramucosal Acidosis in Sepsis 223
References 225
Refining the Tools for Early Goal-directed Therapy in Septic Shock 227
Introduction: Initial Management of Septic Shock 227
Overview of Early Goal-directed Therapy 227
Therapeutic Steps and Goals and Proposed Refinements 230
Other Issues 236
Conclusion 237
References 238
VI Intravenous Fluids 241
Hyperchloremic Metabolic Acidosis: More than Just a Simple Dilutional Effect 242
Introduction 242
Mechanisms Underpinning pH Regulation: A Physico-chemical Approach 242
Effects of Plasma Volume Expansion on pH 244
Clinical Consequences of Hyperchloremic Metabolic Acidosis 245
Conclusion 251
References 251
Old versus New Starches: What do We Know about their Differences? 254
Introduction 254
Hydroxyethyl Starch Pharmacokinetics 254
Volume Effects 255
Renal Effects 257
Coagulation and Bleeding 257
Tissue Storage 259
Pruritus 259
Long-term Survival 260
Conclusion 260
References 261
Impact of Hydroxyethyl Starch on Renal Function 264
Introduction 264
Pharmacokinetic Profile of HES Solutions 264
Pathomechanisms of HES-induced Renal Dysfunction 266
Clinical Evidence of HES-induced Renal Dysfunction 268
Conclusion 271
References 272
Rational Approach to Fluid Therapy in Acute Diabetic Ketoacidosis 275
Introduction 275
Historical Perspective 275
Pathophysiology 276
Aims of Fluid Therapy 277
Optimal Management 278
Conclusion 282
References 282
VII Hemodynamic Support 284
Cardiac Filling Volumes and Pressures in Assessing Preload Responsiveness during Fluid Challenges 285
Introduction 285
Goals and Effects of Fluid Loading: Defining Preload and Fluid Responsiveness 285
Filling Pressures and Volumes of the Heart 286
Physiological Considerations and Clinical Implications 288
Conclusion 291
References 292
Update on Preload Indexes: More Volume than Pressure 295
Introduction 295
Filling Pressures (CVP and PAOP) 295
Continuous Right Ventricular End-diastolic Volume (cRVEDV) 297
Global-end Diastolic Volume and Intrathoracic Blood Volume 299
Conclusion 302
References 302
Monitoring Arterial Blood Pressure and Cardiac Output using Central or Peripheral Arterial Pressure Waveforms 305
Introduction 305
Wave Contour in the Central and Peripheral Arteries 306
Agreement between Central and Peripheral Blood Pressure in Specific Clinical Situations 308
Influence of the Site of Blood Pressure Measurement on Continuous Cardiac Output Estimation 309
Conclusion 314
References 314
Intrathoracic Pressure Regulation for the Treatment of Hypotension 317
Introduction 317
Active Intrathoracic Pressure Regulation Therapy for Apneic Hypotension Patients 317
Intrathoracic Pressure Regulation Therapy and CPR 319
Intrathoracic Pressure Regulation Therapy and Survival Outcomes in Hemorrhagic Shock 320
Intrathoracic Pressure Regulation Therapy and Sepsis 322
Potential Adverse Consequences and Limitations of Intrathoracic Pressure Regulation Therapy 323
Conclusion 323
References 324
Functional Hemodynamic Monitoring: A Personal Perspective 326
Introduction 326
Use of Dynamic Responses to Identify Nascent Cardiovascular States 327
Preload Responsiveness 327
Cardiovascular Sufficiency 328
Future Trends 329
References 330
VIII Airway Management 331
Endotracheal Intubation in the ICU 332
Introduction 332
Care Management Bundle to Increase the Safety of Endotracheal Intubation in the ICU 332
Conclusion 338
References 339
Pediatric Advanced Airway Management Training for Non-anesthesia Residents 341
Introduction 341
Risks associated with Tracheal Intubation and Provider Competence 341
Demand for Pediatric Airway Management Competence in Pediatric Resident Trainees 344
Process of Acquisition and Retention of Pediatric Tracheal Intubation Competence 345
Future Directions 348
Conclusion 348
References 349
Automatic Tube Compensation in the Weaning Process 351
Introduction 351
Automatic Tube Compensation 352
Commercially available Automatic Tube Compensation Systems 352
Potential Clinical Uses of Automatic Tube Compensation 353
Practical Aspects of using Automatic Tube Compensation 356
Conclusion 356
References 356
IX Mechanical Ventilation 358
Extracorporeal Membrane Oxygenation for Cardiac and Pulmonary Indications: Improving Patient Safety 359
Introduction 359
Application of ECMO Today 360
Further Development of ECMO 361
Control and Safety 363
References 366
Patient-ventilator Interaction during Non-invasive Ventilation 368
Introduction 368
NIV in Acute Respiratory Failure 368
Triggering of the Ventilator 369
Pressurization Slope 371
Level of Pressure Support 371
Cycling 372
Masks 373
Conclusion 374
References 374
Variable Mechanical Ventilation: Breaking the Monotony 377
Introduction 377
Patterns of Variability and their Characterization 377
Rationale for the Use of Variable Patterns in Mechanical Ventilation 379
History of Variable Mechanical Ventilation 379
Variable Controlled Mechanical Ventilation 380
Variable Assisted Mechanical Ventilation 381
Why does Respiratory Function Improve during Variable Mechanical Ventilation? 382
Is Variable Mechanical Ventilation Equivalent to Regular Ventilation with Intermittent Sighs? 384
Can Variable Mechanical Ventilation be Injurious? 385
Limitations of Variable Mechanical Ventilation 386
Conclusion 386
References 387
Life-threatening Asthma: Focus on Lung Protection 390
Introduction 390
Epidemiology 390
Definitions 391
Risk Factors 391
Pathophysiology of the Acute Asthma Attack 391
Therapeutic Approach 393
Conclusion 398
References 399
X Respiratory Monitoring 401
Bedside Monitoring of Diaphragm Electrical Activity during Mechanical Ventilation 402
Introduction and Background 402
Bedside Monitoring of EAdi 404
Conclusion 407
References 408
Electrical Impedance Tomography 411
Introduction 411
How Electrical Impedance Tomography Works 411
Clinical Applications 415
Potential Future Applications of Clinical Relevance 419
Conclusion 419
References 420
Regional Ventilation Delay Index: Detection of Tidal Recruitment using Electrical Impedance Tomography 422
Introduction 422
Individual PEEP Setting is Essential 422
Global and Regional Lung Function Parameters 423
Elecrical Impedance Tomography 423
The Concept of the Regional Ventilation Delay Index 424
Implementing Regional Ventilation Delay Index in Clinical Practice 425
Conclusion 428
References 428
Different Approaches to the Analysis of Volumetric Capnography 430
Introduction 430
Capnography: Types and Applications 430
Techniques for Volumetric Capnography Analysis 433
A New Algorithm for Volumetric Capnography Analysis 435
Conclusion 438
References 439
Variation in Extravascular Lung Water in ALI/ARDS Patients using Open Lung Strategy 441
Introduction 441
Measurement of EVLW at the Bedside 441
EVLW in ALI/ARDS Patients 444
Ventilation Strategy in ALI/ARDS and EVLW Variations 444
Conclusion 447
References 447
Clinical Utility of Extravascular Lung Water Measurements 450
Introduction 450
Measurement of EVLW 450
Limitations of the Measurement of EVLW by Transpulmonary Dilution Techniques 452
Clinical Utility of EVLW 455
Conclusion 457
References 457
XI Perioperative Management 460
Rationalizing the Use of Surgical Critical Care: The Role of Cardiopulmonary Exercise Testing 461
Introduction 461
Why Use Cardiopulmonary Exercise Testing as an Assessment Tool? 462
Which Patients should Undergo Cardiopulmonary Exercise Testing? 463
Cardiopulmonary Exercise Testing in Practice 464
Interpretation of Cardiopulmonary Exercise Test Data 466
Risk Stratification and Management using Cardiopulmonary Exercise Testing 468
Case Reports 469
Conclusion 475
References 475
Advanced Minimally Invasive Hemodynamic Monitoring of the High-risk Major Surgery Patient 477
Introduction 477
Definition and Role of Perioperative Optimization 477
Overview of Some Current Advanced Hemodynamic Monitors 479
Decline in Use of Central Venous Catheterization for Major Surgery 486
Conclusion 486
References 486
Post-pneumonectomy Pulmonary Edema 489
Introduction 489
Diagnostic Criteria 489
Prevalence 489
Pathology 490
Etiology 490
Conclusion 495
References 496
The Role of Phenylephrine in Perioperative Medicine 499
Role of the Calcium Sensitizer, Levosimendan, in Perioperative Intensive Care Medicine 514
Inhaled Nitric Oxide Therapy in Adult Cardiac Surgery 527
XII Cardiac Function 536
Use of Natriuretic Peptides in the Emergency Department and the ICU 537
Abnormalities of the ST Segment 545
Functional Mitral Regurgitation in the Critically Ill 557
XIII Cardiopulmonary Resuscitation 566
Feedback to Improve the Quality of CPR 567
The Post-cardiac Arrest Syndrome 577
Use of a Standardized Treatment Protocol for Post-cardiac Resuscitation Care 587
Therapeutic Hypothermia after Cardiac Arrest 601
XIV Renal Function 612
Biomarkers of Acute Kidney Injury in Critical Illness 613
The Role of Biomarkers in Cardiac Surgeryassociated Acute Kidney Injury 622
Neutrophil Gelatinase-associated Lipocalin: An Emerging Biomarker for Angina Renalis 630
XV Hepatosplanchnic Function 637
How does Intra-abdominal Pressure Affect the Daily Management of My Patients? 638
ICG Clearance Monitoring in ICU Patients 655
Acute-on-Chronic Liver Failure in Cirrhosis: Defining and Managing Organ Dysfunction 667
XVI Nutrition 681
The Curse of Overfeeding and the Blight of Underfeeding 682
Enteral Feeding during Circulatory Failure: Myths and Reality 690
Enteral Nutrition with Anti-inflammatory Lipids in ALI/ARDS 702
Glutamine Supplementation in ICU Patients 712
XVII Glucose Control 723
Burn Causes Prolonged Insulin Resistance and Hyperglycemia 724
Glucose Variability in Critically Ill Patients 733
XVIII Adrenal Function 743
Corticosteroid Biology in Critical Illness: Modulatory Mechanisms and Clinical Implications 744
Corticosteroid Treatment of Patients in Septic Shock 756
XIX Coagulation 764
New Anticoagulants: Anti-IIa or Anti-Xa Agents? 765
Emergency Reversal of Anticoagulants 771
XX Neurological Aspects 782
The Role of Imaging in Acute Brain Injury 783
Monitoring and Managing Raised Intracranial Pressure after Traumatic Brain Injury 801
Sepsis-associated Encephalopathy 809
XXI Malignancies 817
Acute Tumor Lysis Syndrome: Diagnosis and Management 818
Life-threatening Neurological Complications in Patients with Malignancies 827
Should We Admit Critically Ill Cancer Patients to the ICU? 844
XXII Drug Dosing 855
Optimizing Drug Dosing in the ICU 856
Relevant CYP450-mediated Drug Interactions in the ICU 867
XXIII Sedation and Analgesia 875
Sedation and Pain Management in the ICU 876
The Role of Dexmedetomidine in Intensive Care 901
Monitoring Delirium in the ICU 910
XXIV ICU Management 927
Intensive Care for the Elderly: Current and Future Concerns 928
ICU Performance: Managing with Balanced Scorecards 937
XXV End-of-Life Issues 951
Managing Conflict at the End-of-Life 960
Strengths and Weaknesses of Substitute Decision Making in the ICU 970
Subject Index 980