Intensive and Critical Care Medicine (eBook)

Preface 5
Contents 9
List of Contributors 13
Abbreviations 18
Section I - Introduction and Mission 23
1 History of Critical Care Medicine: The Past, the Present and the Future 24
Introduction 24
When Did Critical Care Medicine Begin? 25
The Present: Modern Critical Care Medicine and Intensive Care Units 33
The Future of Critical Care Medicine 35
References 36
2 The Mission of the World Federation of Societies of Intensive and Critical Care Medicine ( WFSICCM) 39
Introduction 39
Definition 40
Standards of Care 42
Recommendations 42
Conclusions 44
References 46
Section II - Professionalism, Ethics and Evidence Based Practice 47
3 Professionalism 48
Introduction and Implication 48
Medical Professionalism in the Changing World 49
A Physician Charter and Fundamental Principles 50
Conclusions 57
References 58
4 Ethics of Decision Making in Critical Care 60
Introduction 60
The Nature of the Patient 60
The Emergence of Managed Care 61
The Four Principles of Bio-Ethics 61
Managing Competing Ethical Imperatives 63
Conclusions 64
References 64
5 Evidence- Based Medicine in Critical Care 66
Introduction 66
Definition 66
Goal of EBM 67
How Does One Practice EBM? 68
The Five- Step Approach for Practicing EBM 68
Benefits of EBM 73
Limitations in Adopting EBM 73
Relevance of the EBM to the Developing World 74
Special Considerations for Evidence- Based Critical Care Medicine 74
Conclusions 75
References 76
Section III - Clinical Governance 77
6 Clinical Governance: Definitions and Recommendations 78
Definition of Clinical Governance 78
Recommendations for Intensive Care Departments 80
ICU Performance and Quality Improvement 81
References 83
7 Optimization of Limited Resources and Patient Safety 86
Introduction 86
ICU Mission, Vision and Strategic Plan 87
Processes 87
Resources Allocation 88
Patient Safety and Resource Allocation 92
ICU Improving Quality Committee ( IQC) 94
References 96
8 Improving Quality of Care in ICUs 98
Introduction 98
Defining ICU Performance 99
Measuring ICU Performance 100
Framework for Improving ICU Performance 101
Strategies to Improve Performance 103
Information Technologies in Performance Improvement 104
Conclusions and Recommendations 105
References 106
9 Scoring Systems 109
Introduction 109
Definition 110
Needs and Standards of Care 110
Evidence- Based Models 113
Recommendations 113
Conclusions 115
References 117
Section IV - Nursing Perspectives 121
10 Nursing Workforce Management in Intensive Care 122
Introduction 122
Definition 123
Needs 124
Standards 125
Recommendations 128
Conclusions 129
References 130
11 Intensive and Critical Care Nursing Perspectives 133
Introduction 133
Definition 135
Needs 136
Education 141
Research 141
Management 142
Standards 142
WFCCN Objectives 143
Recommendations 144
Conclusions 144
References 145
Section V - Central Nervous System, Circulation and Kidney 147
12 Central Nervous System Monitoring 148
Introduction 148
ICP Monitoring 148
Treatment of Intracranial Hypertension 150
Controversies 152
What is the Target ICP? 152
Multimodal Monitoring 153
References 154
13 Definition, Monitoring, and Management of Shock States 155
Introduction 155
Definition and Characteristics 155
Monitoring in Patients with Shock 156
Management of Shock 159
Recommendations and Conclusions 161
References 162
14 Plasma Volume Expansion: The Current Controversy 163
Introduction 163
Albumin 164
Hydroxyethyl Starch 165
Renal Impairment 166
Coagulopathy and Thrombocytopenia 167
Tissue Uptake and Storage 168
Issue of Cumulative Dosage 168
Dextran and Gelatin 168
Crystalloids 169
Differences in Hemodynamic Effects Between Crystalloids and Colloids 170
Conclusions 171
References 171
15 Predicting the Success of Defibrillation and Cardiopulmonary Resuscitation 174
Introduction 174
Definition 175
Needs 175
Standards for Predicting Success of Defibrillation and Return to Spontaneous Circulation 176
Analyses of ECG Features During Ventricular Fibrillation and CPR 177
Our Approach: Amplitude Spectrum Area ( AMSA) 179
New Approach to Predict Success of Defibrillation 181
Conclusions 181
References 182
16 Acute Renal Failure 185
Introduction 185
Definition 185
Epidemiology 186
Etiology 186
Sepsis and Renal Failure 193
Prevention of Acute Renal Failure 194
Standards of Care in Renal Failure 196
Dialysis Modalities in the Intensive Care Unit 196
Renal Support Versus Renal Replacement 197
Evidence- Based Selection of Dialysis Modality 198
Recommendations 199
Conclusions 199
References 200
Section VI - Respiratory System and Protective Ventilation 202
17 The Evolution of Imaging in Respiratory Dysfunction Failure 203
Introduction 203
Chest X- rays 204
CT Scan 206
References 213
18 ALI, ARDS, and Protective Lung Ventilation 215
Introduction 215
Definitions and Diagnosis 215
Epidemiology and Outcomes 217
Histopathology 218
Pathophysiology 218
Treatment 218
Recommendations 224
References 224
Section VII - Infections Surveillance, Prevention and Management 227
19 From Surveillance to Prevention 228
Introduction 228
Definition 229
Needs 233
Standard of Care 233
Evidence Based 237
Recommendations 239
Conclusions 239
References 240
20 Antibiotic Policy in Critically Ill Patients 244
Introduction 244
General Guidelines for the Use of Antimicrobial Agents in Critically Ill Patients: The 10 Recommendations 245
General Strategies of Antibiotic Use in Critical Patients 251
Conclusions 253
References 253
21 The Physiopathology of Antimicrobial Resistance on the Intensive Care 257
Introduction 257
Normal vs. Abnormal Flora 257
Four Stages in Resistance 258
Traditional Approach to Antimicrobial Resistance 259
The Selective Decontamination of the Digestive Tract ( SDD) Approach 261
References 263
22 Infections in ICU: An Ongoing Challenge 266
Introduction 266
Time vs. Carrier State Classification of Pneumonia 268
Nonantibiotic Measures to Prevent Pneumonia 270
Conclusions 273
References 274
23 Selective Decontamination of the Digestive Tract ( SDD). Twenty- five Years of European Experience 278
Introduction 278
Definition 279
Efficacy 279
Safety 280
Costs 283
SDD: The Only EBM Maneuver with Grade 1A Recommendation 283
Practical Guidelines: How To Do SDD 284
References 285
24 Antifungal Management 289
Introduction 289
Definition of the Topic 290
Identification of Risk Factors 290
Diagnosis of Candida Invasive Infections in ICU 291
Diagnosis of Invasive Pulmonary Aspergillosis in ICU 292
Antifungal Agents 294
Recommendations for Management of Invasive Candida Infection 296
Recommendations for Management of Invasive Aspergillus Infection 297
Conclusions 298
References 298
Section VIII - Sepsis, Organ Dysfunction and the Bundles 301
25 Sepsis: Clinical Approach, Evidence- Based at the Bedside 302
Introduction 302
Definitions 303
Pathophysiology of Sepsis 304
Diagnosis and Clinical Evaluation 305
Evidence- Based Clinical Management of Severe Sepsis 308
Initial Resuscitation 309
Maintenance Therapy 311
References 314
26 Intra- Abdominal Infections: Diagnostic and Surgical Strategies 317
Introduction 317
Definition and Classification 317
Microbiology of IAIs 318
Inflammatory Response in Peritonitis 319
Diagnosis 320
Management 321
Conclusions 324
References 324
27 Surviving Sepsis Campaign and Bundles 327
Introduction 327
The Surviving Sepsis Campaign 327
Needs and Limitations 330
Conclusions and Recommendations 331
References 332
Section IX - Trauma 334
28 The Trauma: Focus on Triage 335
Introduction 335
Triage in Mass Casualty Incidents, War, and Disasters 336
Reverse Triage 337
Treatment Priorities in Multiple Casualty Incidents ( MCI) 338
Special Triage Situations 339
Limitations and Pitfalls of Triage 341
Civilian Field Triage 341
Trauma Centers 342
Hospital Triage 345
Resource- Limited Hospital Triage 346
Triage in the Emergency Department 346
Conclusions 348
References 348
29 Damage Control in Surgery 352
Introduction 352
Definition 352
History 353
Incidence 353
Indications and Timing for Damage Control 353
Stages of Damage Control Surgery Damage control surgery is a three- stage approach: 355
Damage Control in Specific Injuries 357
Conclusions 361
References 361
Section X - Limited Resource, Disaster 363
30 Emergency Mass Critical Care 364
Introduction 364
Definition 365
Considerations 365
Risk 367
Needs 368
Recommendations 368
Staff 369
Conclusions 373
References 374
31 Natural Disaster 376
Introduction 376
Definition, Classification, and Epidemiology 377
Injuries and Illness Related to Disasters 378
Response to Natural Disasters: Focus on Critical Care Professionals 382
Conclusions 386
References 386
32 The Needs of Children in Natural or Manmade Disasters 388
Introduction 388
The Particular Needs of Children 393
Resources for Care of Children in Disasters 399
Ethics Related to Children in Disasters 405
Dealing with the Long- term Consequences 406
Conclusions 406
References 406
Suggested resources 411
Section XI - Special Clinical Conditions 412
33 The Neuroendocrine Response to Sepsis 413
Introduction 413
Physiology of the Endocrine Response 414
Physiological Control of the Endocrine System 414
Potential Mechanisms of Regulation of the Endocrine Activity During Critical Illness 421
Endocrine Activity During Critical Illness 422
Clinical Consequences of Endocrine Activity in Critical Illness 424
Conclusions 427
References 428
34 Blood Transfusion and Its Components 430
Introduction 430
Anemia in Critically Ill Patients 431
When Should Critically Ill Patients Be Transfused? 432
Blood Transfusion in Patients Receiving Mechanical Ventilation 433
Transfusion in Patients With Ischemic Heart Disease 434
The Benefits and Risks of Transfusions 434
Blood Transfusion and Mortality 435
The Use of Fresh Frozen Plasma 437
Conclusions 438
References 438
35 Pain Management in Neonates and Children 441
Introduction 441
Pain Assessment 441
Pain Management 445
Conclusions 459
References 459
36 Obstetrics at High Risk 462
Introduction and Definition 462
Thromboemolic Disease 466
Hypertensive Disease 467
Drug Abuse 472
ICU Management 473
Specific Issues 474
Fluids and Inotrops 474
Sepsis 476
Delivery of Fetus 476
Cardiopulmonary Resuscitation 476
Perimortem Caesarean Section 477
Conclusions 477
References 477
37 Intensive Care in the Elderly 480
Introduction 480
Definitions 480
Needs 484
Standards of Care 486
Recommendations 487
Conclusions 491
References 491
38 Severe Malaria in the ICU 494
Introduction 494
Magnitude of the Problem 494
Parasitology 495
Pathophysiology 495
Clinical Features of Severe Malaria 496
Laboratory Diagnosis 497
Newer Methods 498
Severe Malaria – Intensive Care Management 499
Malaria and Pregnancy 503
Prognostic Indicators 503
Challenges for the Future 504
References 504
39 End-of-Life in the ICU 507
Introduction 507
Definitions 507
Decision- Making in End- of- Life Care 510
Conclusions 511
References 512
Section XII - Environment and Clinical Research 514
40 Designing Safe Intensive Care Units of the Future 515
Historical Background 515
Patient Safety and National Health Policy Drivers of ICU Care 516
Current Critical Care Crisis 517
Traditional ICU Design Approach 518
New Innovations in Design of Healthcare Facilities 520
Patient Safety Research Roadmap in the ICU ( Table 40.1) 522
Conclusions 530
Suggested Reading 531
41 How to Plan and Design a Clinical Research Project 532
Introduction 532
Research Question 533
Background Information and Relevance 533
Aim and Objective( s) 533
Design 534
Subject 542
Variables 543
Statistical Issues 544
Analysis Approach 548
Ethical Considerations 549
Suggested Reading 550
Subject Index 551