Yearbook of Intensive Care and Emergency Medicine 2010 (eBook)

Title Page 2
Copyright Page 3
Table of Contents 4
List of Contributors 8
Common Abbreviations 19
I The Microcirculation 20
The Microcirculation and Oxidative Stress 21
Introduction 21
Reactive Oxygen Species 21
Sources of ROS in the Microcirculation 23
Mitochondria 23
NADPH Oxidase 23
NO Synthase 24
Xanthine Oxidase 24
Other Sources of Superoxide Anion Production 25
Interactions of ROS with the Microcirculation 25
Leukocyte-endothelial Cell Adhesion 26
Vascular Tone Regulation 27
The Vast Spectrum of Intracellular Targets for ROS 27
Role of Oxidative Stress in Microcirculatory Dysfunction 28
Ischemia-reperfusion 28
Sepsis 29
Conclusion 31
References 31
Diagnosis and Treatment of the Septic Microcirculation 34
Introduction 34
Normal Microcirculation 34
The Microcirculation in Sepsis 36
Bedside Study of the Microcirculation 37
The Microcirculation in Distributive Shock 37
Recruiting the Microcirculation Network During Distributive Shock 41
Conclusion 42
References 43
Targeted Treatment of Microvascular Dysfunction 45
Introduction: Microvascular dysfunction is the Root Cause of Inflammatory Organ Dysfunction 45
Traditional Therapies and Biomarkers have Centered on the Macrocirculation 45
New Methods of Assessing the Microcirculation 46
Therapeutic Approaches 47
Suppression of Intracellular Inflammatory Signaling 47
Other inhibitors of cellular inflammation 48
Suppression of Circulating Mediators of Inflammation 49
Large scale removal by hemofiltration 49
Intravenous immunoglobulin 49
Neutralizing antibodies 49
Coagulation 50
Conclusion 50
References 51
II Hemodynamic Monitoring 54
Diagnosing Hypovolemia in Critically Ill Patients 55
Introduction 55
Defining Hypovolemia 55
Diagnosing Hypovolemia 55
Static Diagnostic Tests 56
Dynamic Diagnostic Tests 56
Fluid challenge 56
Arterial waveform-derived variables 56
Passive leg raising 58
Perspective 59
Conclusion 60
References 60
Measuring Stroke Volume Using Electrical Impedance Tomography 62
Introduction 62
Why do we need Non-invasive Cardiovascular Measurements? 62
Electrical Impedance Tomography 63
EIT-based Methods to Measure Stroke Volume 64
Holding the Breath 64
EKG Gating 64
Optimized Separation in the Temporal and Spatial Domains 65
Contrast Agents 66
Deriving Stroke Volume from Cardiac Impedance Images 67
Impedance-time Curves 68
Parametric EIT 69
Conclusion 69
References 70
Direct Arterial Pressure Monitoring: Pattern Recognition in the Management of Circulatory Failure 72
Introduction 72
Case Study 1: Components of an Arterial Pressure Waveform 72
Case Study 2: Hypovolemia 73
Case Study 3: Pulse Pressure as a Measure of Stroke Volume 74
Case Study 4: Effect of Aortic Capacitance on Pulse Pressure 75
Case Study 5: Effect of Vasoconstrictor Drugs on Pulse Pressure 75
Case Study 6: Effect of Vasoconstriction on the Dicrotic Notch and Secondary Pressure Waves 76
Case Study 7: Sympathetic Stimulation and Reflected Pressure Waves 77
Conclusion 78
References 78
Choosing Patient-tailored Hemodynamic Monitoring 80
Introduction 80
What Do We Have and What Can they Do? 80
Factors Affecting Choices 83
Conclusions and Perspective 85
References 85
III Resuscitation Issues 88
Airway and Ventilation during CPR 89
Introduction 89
Regurgitation and Aspiration after Cardiac Arrest 89
The Pros and Cons of Tracheal Intubation 90
Advantages of Tracheal Intubation 90
Disadvantages of Tracheal Intubation 90
Reducing the Risk of Unrecognized Esophageal Intubation 91
Supraglottic Airway Devices 91
Ventilation during CPR 92
Passive Oxygen Insufflation 92
Mouth-to-mouth Ventilation 93
Conclusion 93
References 94
The Role of Gasping in Resuscitation 97
Introduction 97
The Frequency of Gasping in Global Ischemic Events 98
The Meaning of Gasping in Global Ischemic Events 99
The Unique Physiology of Sudden Circulatory Collapse 100
Gasping as an Independent Factor for Improving Survival 102
Improved Airflow, Blood Flow, or Both? 103
Using Gasps to Avoid the Detriments of Positive Pressure Breaths 104
Better Detection of Cardiac Arrest Using Gasps 105
The Role of Gasping in Trauma Care and Infant Resuscitation 106
Creating Gasps for Those Who Do Not Do So 107
Conclusion 107
References 107
Recent Concepts in Burn Resuscitation 110
Introduction 110
Resuscitation Perspectives 110
Can Metabolic Markers Guide Resuscitation and Help Predict Outcomes? 112
Military Resuscitation Experience (Tables 1 and 2) 114
Nurse-driven Resuscitation 116
Consensus Statements 118
Conclusion 119
References 119
Intra-aortic Balloon Counterpulsation in Cardiogenic Shock 121
Introduction 121
What do the Guidelines tell Us and What about ‘Real Life’? 122
Does Hemodynamic Improvement Improve Prognosis in Infarction-triggered Cardiogenic Shock? 122
Effects of IABP on Hemodynamics, Systemic Inflammation and MOF in Infarction-triggered Cardiogenic Shock 124
What Does a Meta-Analysis Tell Us? 125
Beyond IABP: Do We Have Better Alternatives for the Treatment of Cardiogenic Shock? 127
Impella® Pump 127
Extracorporeal Membrane Oxygenation (ECMO) 127
Tandem Heart® 128
Assisted Extracorporeal Life-support in Adults with In-hospital Cardiac Arrest 128
IABP versus Percutaneous LVAD in Cardiogenic Shock: A Meta-analysis 128
We Should Change the Guidelines for IABP Use in Infarction-triggered Cardiogenic Shock! 128
Intra-aortic Balloon Counterpulsation in Septic Shock? 129
Conclusion 131
References 131
IV Inflammatory Responses in the Lung 133
Vascular Endothelial Growth Factor in Acute Lung Injury 134
Introduction 134
Biology of VEGF 134
VEGF Receptors 135
Cellular Source of VEGF within the Lung 135
Cellular Actions of VEGF 135
VEGF as a Pathophysiological Driver of Acute Lung Injury? 136
VEGF Compartmentalization in Acute Lung Injury 137
Tissue Studies 137
Regulation of VEGF Bioactivity 138
Is there a Unifying Hypothesis for the Role of VEGF in Acute Lung Injury? 138
Conclusion 138
References 140
Role of CD14 in Lung Inflammation and Infection 142
Introduction 142
CD14 and the LPS Receptor Complex 144
CD14 and other Pattern Recognition Receptors 145
Role of CD14 in LPS- and LTA-induced Lung Inflammation 146
Role of CD14 in Lung Infection 148
Conclusion 151
References 151
V Mechanical Ventilation 154
Measurement of Functional Residual Capacity during Mechanical Ventilation 155
Introduction 155
Methods for FRC Measurement During Mechanical Ventilation 156
Closed Circuit Techniques 156
Open Circuit Wash-in/washout Procedures 159
Respiratory Inductive Plethysmography 161
Computed Tomography Scan 162
Conclusion 162
References 163
New and Conventional Strategies for Lung Recruitment in Acute Respiratory Distress Syndrome 166
Introduction 166
Definition and Factors Affecting Recruitment Maneuvers 167
Nature and Extent of Lung Injury 168
Patient Positioning 168
Types of Recruitment Maneuver 169
Impact of Recruitment Maneuver on Ventilator-induced Lung Injury 169
The Role of Variable Ventilation as a Recruitment Maneuver 171
Conclusion 172
References 173
Consequences of Pleural Effusions for Respiratory Mechanics in Ventilated Patients 176
Introduction 176
Origin of Pleural Effusions in the Critically Ill Patient 176
Modeling the Pleural Effusion-lung Interaction 177
Pleural Effusion and Respiratory Mechanics 178
Effects of Pleural Effusion on Gas Exchange 180
Practical Implications for the Mechanically Ventilated Patient with Pleural Effusion 181
Pleural Effusions and Ventilator-induced Lung Injury? 183
Conclusion 184
References 184
Weaning Failure of Cardiac Origin: Recent Advances 187
Introduction 187
Mechanisms Contributing to the Development of Weaning-induced Pulmonary Edema 187
Diagnosis of Weaning-induced Pulmonary Edema 188
Clinical Context 188
Right Heart Catheterization 188
Transthoracic Echocardiography 189
Cardiac Biomarkers 190
Detection of Weaning-induced Hemoconcentration 191
Therapeutic Options 192
Conclusion 193
References 193
VI Respiratory Failure 195
The Effects of Pleural Effusion 196
Introduction 196
Pathogenesis 196
Effects of Acute Pleural Effusion on Lung Volume, Respiratory System Mechanics, and Gas Exchange 197
Effects of Thoracentesis on Lung Volume, Respiratory System Mechanics, and Gas Exchange 198
Pleural Effusion in Patients with ALI/ARDS 200
Conclusion 201
References 202
Fluid Management in Acute Lung Injury and ARDS 204
Introduction 204
The Consequences of Pulmonary Edema during ARDS 204
ARDS: Lesional or Hemodynamic Edema? 205
Resorption and Drainage of Pulmonary Edema 207
Fluid Restriction and Diuretics: Clinical Studies and Practical Consequences 207
Modulation of Oncotic or Osmotic Pressure: The Effects of Administering Albumin or Hypertonic Saline 209
Increasing Resorption of Alveolar Edema – A Complementary Objective 211
Conclusion 211
References 211
Life-threatening Respiratory Failure from H1N1 Influenza: Lessons from the Southern Cone Outbreak 214
Introduction 214
Why was Pandemic (H1N1) 2009 Flu So Prevalent in the Southern Cone? 214
How Big was the Outbreak? 215
Common Complications of Influenza 216
Risk Factors for the Acquisition of Severe H1N1 2009 Primary Influenza Pneumonia 218
Differences Comparing this Pandemic with the usual Seasonal Flu 218
Management 218
Non-pharmacologic Therapy 219
Ventilatory settings 219
Recruitment maneuvers 220
Prone position ventilation 220
Adjunctive therapies to mechanical ventilation 221
Pharmacologic Therapy 221
Antivirals 221
Antibacterial antimicrobials 222
Corticosteroid therapy 222
Complications 222
Bacterial Infection 222
Pulmonary Embolism 223
Extrapulmonary Manifestations 223
Renal Failure 223
Cryptogenic Organizing Pneumonia 223
Prognostic Factors for Fatal Influenza Pneumonia 224
Preventive Measures 224
Conclusion 224
References 225
VII Infections 227
Cytomegalovirus Infections in Non-immunocompromised Critically Ill Patients 228
Introduction 228
Clinical Studies 228
Conclusion 231
References 231
Prevention of Central Venous Catheter-related Infection in the Intensive Care Unit 232
Introduction 232
Catheter Care Protocols 233
Staff Educational/Quality Improvement Program 233
Type of Catheter 234
Catheter Insertion Site 235
Ultrasound-guided Placement 236
Insertion Technique 236
Skin Antisepsis 236
Antibiotic Prophylaxis 237
Tunneling 238
Dressing 238
Venous Line Maintenance 239
Conclusion 240
References 241
Standardization of Care to Improve Outcomes of Patients with Ventilator-associated Pneumonia and Severe Sepsis 244
Introduction 244
Prevention and Treatment of VAP 244
Severe Sepsis and Septic Shock 248
Conclusion 250
References 250
Strategies for Implementation of Evidence-based Guidelines for Prevention of Healthcare-associated Infection 253
Introduction 253
Guidelines 253
Adherence to Guidelines 254
Barriers 255
Facilitators 256
Theories of Change 256
Implementation Research 257
Implementation Interventions and Strategies 257
Short Historical Overview 258
The 1990s 258
The 2000s 258
Current insights 259
Implementation of Infection Prevention Guidelines 259
Interventional studies 259
Systematic review 260
Evaluating the Implementation 262
Cost Considerations 262
Conclusion 263
References 263
Antibiotic Stewardship: Possibilities when Resources Are Limited 266
Introduction 266
STEP 1-Include the Antibiotic Stewardship Program within the Hospital Infection Control Program 266
STEP 2-Be Aware of the Different Antibiotic Stewardship Program Strategies 268
STEP 3-Define the Core Strategy/Key Antibiotics/Areas to Include within the Antibiotic Stewardship Program According to the Institution’s Resources 272
STEP 4-Develop and Define Institution-adapted Antibiotic Stewardship Program Performance Indicators 274
Conclusion 274
References 275
VIII Metabolic Support 279
Vitamin D in Critical Illness 280
Introduction 280
Historical Perspective 280
Circadian Rhythm of Vitamin D 281
Pleiotropic Effects of Vitamin D 281
Vitamin D and the Musculoskeletal System 281
Vitamin D and Cardiovascular Disease 283
Vitamin D and the Immune System 283
Vitamin D and Sepsis 284
Miscellaneous Effects of Vitamin D 285
Vitamin D in Critical Illness 285
Challenges for the Intensivist 285
References 286
IX Anticoagulant Therapies 289
Update on Antithrombin for the Treatment of Burn Trauma and Smoke Inhalation Injury 290
Introduction 290
Antithrombin 291
Therapeutic Effects of Antithrombin 291
Anticoagulant Effects 292
Anti-inflammatory effects dependent on the coagulation system 292
Coagulation-independent anti-inflammatory effects 292
Interactions with Heparin 294
Antithrombin for the Treatment of Burn Trauma and Smoke Inhalation Injury 295
Experimental Studies 295
Clinical Studies 297
Conclusion 299
References 299
Update on Physiological Anticoagulant Factor Concentrates in Patients with Sepsis 302
Introduction 302
Inflammation-induced Effects on Physiological Anticoagulant Factors 302
The Antithrombin System 303
The Thrombomodulin-protein C System 304
Tissue Factor Pathway Inhibitor 305
Effects of Natural Anticoagulant Systems on Inflammation 305
Clinical Application of Natural Anticoagulant Factor Concentrates 307
Antithrombin Concentrate 307
Recombinant Human Activated Protein C 308
Soluble Thrombomodulin 311
Recombinant Tissue Factor Pathway Inhibitor 311
Conclusion 312
References 312
X Anemia and Blood Transfusions 315
Venous Oxygen Saturation as a Physiologic Transfusion Trigger 316
Introduction 316
Venous Oxygen Saturation as a Physiologic Transfusion Trigger 316
The Concept of Physiologic Transfusion Trigger 320
Conclusion 322
References 322
Tissue Protective Activities of Erythropoietin 324
Introduction 324
EPO and Tissue Protection 325
Tissue Protection and Clinical Trials 326
Erythropoiesis versus Tissue Protection 327
Conclusion 328
References 329
XI Renal Disease and Therapy 332
Doppler-Based Renal Resistive Index: A Comprehensive Review 333
Introduction 333
Technique 334
Physiological Significance of the Renal Resistive Index 335
Doppler-Based Renal Resistive Index in Selected Renal Diseases 336
Non-obstructive Renal Diseases 336
Obstructive Renal Diseases 336
A Promising Tool in Critically Ill Patients? 337
Conclusion 337
References 338
Atrial Natriuretic Peptide in Postoperative Acute Renal Failure 341
Introduction 341
The Discovery of the Atrial Natriuretic Peptide System 341
Renal Effects of ANP in Humans 342
Renal Blood Flow 342
Glomerular Filtration Rate 342
Tubular Effects of ANP 342
Effects of ANP on Renal Oxygen Consumption 343
Effects of ANP on Renal Blood Flow and GFR in Postoperative Acute Renal Failure 343
Effects of ANP on Renal Outcome in Acute Renal Failure 344
Effects of ANP in Other Forms of Clinical Acute Renal Failure 347
Cyclosporine-induced Acute Renal failure 347
Liver Transplantation 347
Radiocontrast-induced Nephropathy 347
Meta-Analysis of ANP in the Management of Acute Renal Dysfunction 347
Conclusion 348
References 348
Renal Dysfunction in Chronic Liver Disease 351
Introduction 351
Co-existing Liver and Kidney Disease 351
Serum Creatinine Concentration for the Assessment of Kidney Function in Chronic Liver Disease 353
Acute Kidney Injury Network Criteria for staging Acute Kidney Injury 354
Acute Kidney Injury Pathogenesis 355
Patients with Chronic Liver Disease are more Susceptible to Acute Kidney Injury 355
Hepatorenal Syndrome 356
Acute Kidney Injury and Chronic Liver Disease 357
Biomarkers of AKI 358
Kidney Disease Outcome Quality Initiative Criteria for Staging Chronic Kidney Disease 358
Assessment of Chronic Kidney Disease in Patients with Chronic Liver Disease 361
Future Directions 361
Orthotopic Liver Transplantation 362
Conclusion 363
References 364
Hemofiltration and Hybrid Therapies in 2010 367
Introduction 367
Mechanisms of Removal and Transport by Synergistic Action of HVHF and Enhanced Adsorption 368
Synergistic action of HVHF and Enhanced Adsorption: Clinical Feasibility and Effects beyond Hemodynamics 368
New Pathophysiological Insight regarding Septic Acute Kidney Injury 370
Update on Very Recent Trials in Critically ill Patients with AKI 371
Conclusion 372
References 372
Timing of Renal Replacement Therapy 375
Introduction 375
AKI: An Historical Overview 375
A Problem of Uremia 375
The Concept of Prophylactic Dialysis 376
From Acute Renal Failure to AKI, and from Renal Replacement Therapy to Renal Support: A Paradigm Shift 376
Definition of Timing of Initiation of RRT in ICU Patients 378
What does the Evidence tell Us? 378
Urea 378
Volume overload 378
Early initiation in the course of AKI 378
Future Directions: Early Goal-directed Therapy to Improve Renal Outcome 379
Conclusion 379
References 380
XII Neurological Aspects 382
Multimodal Monitoring: A Critical Tool in the Neuro-ICU 383
Introduction 383
Multimodal Monitoring in Hypoxic-Ischemic Encephalopathy 384
Multimodal Monitoring in Traumatic Brain Injury 385
Multi-modal Monitoring in Cerebrovascular Disease 387
Conclusion 389
References 390
Hemodynamic Management of Acute Spinal Cord Injury 392
Introduction 392
Overview of the Incidence and Pathophysiology of Acute Traumatic Spinal Cord Injury-induced Cardiovascular Dysfunction 392
Blood Pressure Augmentation in Patients with Acute Traumatic Spinal Cord Injury 393
Spinal Cord Perfusion Pressure, Intrathecal Pressure, and Treatment 395
Potential Risks of Blood Pressure Augmentation in Acute Spinal Cord Injury 396
Conclusion 396
References 397
Quantitative CT Scan and CT-Estimated Brain Specific Gravity in TBI 399
Introduction 399
Quantitative Computed Tomography 400
Quantative CT Study of Non-contused Hemispheric Areas 402
Quantitative CT Study of Contused Hemispheric Areas 405
Interpretation of Estimated Specific Gravity Variation 406
Conclusion 408
References 409
Cerebral Perfusion in Sepsis 411
Introduction 411
Sepsis and the Brain 411
Inflammation and the Brain 411
Effects of Sepsis on the Blood-brain Barrier and the Vascular Endothelium 412
Cerebral Perfusion 413
Cerebral Perfusion Pressure 413
Regulation of Cerebral Perfusion 413
CO2-reactivity 413
Cerebrovascular pressure autoregulation 414
Perfusion and Brain Dysfunction 414
Cerebral ischemia 414
Cerebral perfusion and sepsis-associated delirium 414
Effects of catecholamines on cerebral perfusion in patients with sepsis 415
Conclusion 415
References 416
Systemic Complications after Subarachnoid Hemorrhage 419
Introduction 419
Cardiac Abnormalities 420
Lung Abnormalities 421
Fever 422
Anemia 422
Hyperglycemia 423
Electrolyte Abnormalities 423
Conclusions 425
References 425
XIII Perioperative Management 428
Epidural Anesthesia: New Indications for an Old Technique? 429
Introduction 429
Effects of Epidural Anesthesia on Pain Management 430
Effects of Thoracic Epidural Anesthesia on Myocardial Function 430
Effects of Thoracic Epidural Anesthesia on Pulmonary Function 431
Effects of Thoracic Epidural Anesthesia on Gastrointestinal Function 431
Effects of Thoracic Epidural Anesthesia on the Immune System 432
Effects of Thoracic Epidural Anesthesia on Long-term Outcome 432
Adverse Effects and Potential Risks of Epidural Anesthesia 433
Conclusion 434
References 434
Risk Assessment and Prevention of Perioperative Stroke 437
Introduction 437
Pathophysiology 437
Review of Clinical Studies 439
Preventive Strategies 447
Conclusion: Proposed/useful Clinical Perioperative Guidelines 449
References 450
Overview of Chronic Post-thoracotomy Pain: Etiology and Treatment 453
Introduction 453
Prevalence 453
Pathology 453
Preoperative Factors 454
Demographic Factors 454
Genetics 454
Psychosocial Factors 454
Preoperative Pain 454
Intraoperative Factors 455
Surgery 455
Analgesia 455
Postoperative Factors 455
Others 455
Strategies for Treating Long Term Pain 457
Conclusion 457
References 457
XIV Abdominal Compartment Syndrome 460
The Polycompartment Syndrome: What’s all the Fuss About? 461
Introduction 461
Pathophysiology 461
Orbital Compartment Syndrome 461
Intracranial Compartment Syndrome 464
Thoracic Compartment Syndrome 465
Cardiac Compartment Syndrome 467
Limb or Extremity Compartment Syndrome 469
Hepatic Compartment Syndrome 471
Renal Compartment Syndrome 471
Pelvic Compartment Syndrome 472
Abdominal Compartment Syndrome 472
Monitoring of intra-abdominal pressure 475
Abdominal perfusion pressure measurement 475
Clinical Management 476
Conclusion 477
References 477
Laparostomy: Why and When? 481
Introduction 481
Who Started Laparostomy? 481
Temporary Abdominal Cover 482
Classification of Open Abdomen 483
Definitive Abdominal Wall Closure 483
Does Laparostomy Improve Outcome? 484
Conclusion 486
References 486
XV Drug Distribution and Clearance 488
Augmented Renal Clearance: Unraveling the Mystery of Elevated Antibiotic Clearance 489
Introduction 489
Defining Augmented Renal Clearance 489
Assessing Renal Function in Critical Illness 490
Changes in Critical Illness Contributing to Augmented Renal Clearance 491
Prevalence and Natural History of Augmented Renal Clearance in the Critically Ill 491
Traumatic Brain Injury 492
Surgery and Trauma 493
Burns 493
Hematological Malignancy 493
Hypoalbuminemia 494
What are the Clinical and Dosing Implications of Augmented Renal Clearance? 494
Concentration-dependent Killing 494
Aminoglycosides 494
Time-dependent Killing 495
ß-lactam antibiotics 495
Oxazolidinone antibiotics 496
AUC0–24/MIC antibiotics 496
Glycopeptides 496
Quinolone antibiotics 497
Therapeutic Drug Monitoring 497
Conclusion 498
References 498
Drug Distribution: Is it a more Important Determinant of Drug Dosing than Clearance? 501
Introduction 501
Overview of Pharmacokinetic and Pharmacokinetic/pharmacodynamic Parameters 501
Volume of Distribution versus Clearance: How do they Affect Serum Drug Concentration and Half-life? 502
Causes and Consequences of Increased Volume of Distribution 503
Chronic Increases in Volume of Distribution 504
Obesity 504
Chronic organ dysfunctions 505
Other scenarios 505
Acute Increases in Volume of Distribution 506
Severe sepsis 506
Burns 506
Hypoalbuminemia 506
Other scenarios 507
Measurement of Volume of Distribution in Critically Ill Patients 507
Clinical Significance and Recommended Dose Strategies 507
Conclusion 508
References 508
XVI Risk Stratification 511
Risk Stratification in Severe Sepsis: Organ Failure Scores, PIRO or Both? 512
Introduction 512
Organ Dysfunction/Failure Scores 513
From Multiple Organ Dysfunction/Failure Scores to the PIRO Concept 514
Should We Have One PIRO Or Many PIROs? 517
Should we use PIRO or MOF Scores? 518
References 519
XVII Critical Care Outreach 522
On the Response to Acutely Deteriorating Patients 523
Introduction: The Deteriorating Patient 523
Sub-optimal Care 523
‘Track and Trigger’ Mechanisms 524
Role of Critical Care Outreach Services 525
Educational Tools 526
Use of Technology as a Tool to ‘Track and Trigger’ 527
Human Factors 528
Conclusion 529
References 529
Identifying Cardiorespiratory Insufficiency Outside the ICU 531
Introduction 531
Existing Non-invasive Cardiovascular Monitoring is Ineffective at Identifying Instability In Step-down Units 532
Integrated Monitoring Systems to Monitor the Monitors 534
Implications 535
References 535
XVIII End-of-life Issues 536
An Update on ICU Management of the Potential Organ Donor 537
Introduction 537
Role of the Intensivist 537
Physiologic Changes Associated with Brainstem Death 538
Protocols for Management of the Potential Organ Donor 538
Management of Individual Organ Systems 539
Cardiovascular 539
Pulmonary 542
Endocrine 543
Renal and Gastrointestinal 544
Coagulopathy and Hypothermia 544
Donation after Cardiac Death 544
Conclusion 546
References 547
End-of-life Care in the ICU: Commonalities and Differences between North America and Europe 550
Introduction 550
Discrepancy between Preferred and Actual Place of Death 550
Use of Critical Care Services during Terminal Hospitalization 551
Health Care Costs during Terminal Hospitalization 551
Variation in End-of-life Intensive Care Use 551
End-of-life Decision-making Process 552
An American Perspective 552
A European Perspective 554
Unintended Consequences of End-of-life Decision-making 555
Conclusion 556
References 556
XIX Patient Care 559
Do Sleep Disorders have an Impact on Outcome in ICU Patients? 560
Introduction 560
Anesthesia/sedation and Sleep are not Identical, but may Share Common Mechanisms 560
Exploring Sleep in ICU Patients 561
Characteristics of Sleep Alteration in ICU Patients 562
ICU Environment 563
Mechanical Ventilation 564
Drugs 564
Impact of Sleep Disturbance on Patient Outcome 565
Therapeutic Interventions to Preserve/improve Sleep (Table 2) 566
Attenuation of Noise and Light 566
Limiting Interventions 567
Changing to Assist-control or Proportional Assist Ventilatory Modes 567
Use of Pharmacological Interventions 567
Conclusion 568
References 568
Communication in Crisis: The Importance of ‘Verbal Dexterity’ 570
Introduction 570
The Importance of Communication and Culture 570
Airway, Breathing, Communication: The New ABCs of Crisis Management 571
“Say what you Mean, and Mean what you Say” 571
Mitigating Speech: “No ifs, and, or Buts” 572
Silence is not always Golden 573
Graded Assertiveness: Getting the Message Across 573
Questioning Authority and Handing Over Responsibility: Underappreciated Skills 574
Practicing Verbal Dexterity 575
Managing Interruptions and Distractions 575
Communication really Ought to have Three Cs 576
Conclusion 576
References 577
Patient Safety and Acute Care Medicine: Lessons for the Future, Insights from the Past 579
Introduction 579
‘The Missing Curriculum’ [3] 579
Engineering and Acute Care Medicine 580
Engineering and Error Prevention 581
Understanding the Basics of Human Error 581
Educating for Safety 582
Maximizing the Best of Human and Machine 583
Other Lessons from the Chessboard 584
Conclusion 584
References 585
Subject Index 586