Care of the Critically Ill Patient

List of Contributors.- Section A. Applied Physiology.- 1 Measurement and Control of Cardiac Output.- Cardiac Output at Rest and on Exercise.- Intrinsic Properties of Heart Muscle.- Coronary Blood Flow.- Assessment of the Heart as a Pump.- Cardiac Output during Exercise and Cardiac Failure.- 2 The Systemic and Pulmonary Circulations.- Functions of the Circulation.- Functional Organization of the Circulation.- The Systemic Circulation.- The Pulmonary Circulation.- Implications of Circulatory Physiology in Critical Care.- 3 Cardiopulmonary Interactions.- I. The Physiology of Cardiopulmonary Interactions Transmural Pressure.- Myocardial Function.- Cardiac Function: Left Heart Versus Right Heart.- The Cardiac Fossa.- Hemodynamic Effects of Ventilation.- Hemodynamic Effects of Changes in Lung Volume.- Hemodynamic Effects of Changes in Intrathoracic Pressure.- II. Clinical Aspects of Cardiopulmonary Interactions.- Negative Changes in Intrathoracic Pressure: Spontaneous Inspiration.- Positive Changes in Intrathoracic Pressure: Spontaneous Expiration.- Positive-Pressure Ventilation: Concepts.- Modes of Mechanical Ventilation.- 4 Pulmonary Ventilation and Gas Exchange.- Ventilation.- Diffusion.- Perfusion.- Ventilation-Perfusion Ratios.- 5 Oxygen Transport and Consumption.- Determinants of Tissue Oxygen Tension.- Classification of Hypoxia.- Recognition of Tissue Hypoxia.- Venous Oxygen Tension as an Index of Tissue Hypoxia.- Tissue Oxygen Extraction.- Physiological Versus Pathological Oxygen Supply Dependence.- 6 Mediator Systems of Lung Injury.- Humoral Mediators.- Cellular Mediators.- Conclusions.- 7 Fluid and Electrolyte Balance.- Distribution of Body Water.- Relationship Between Plasma and Interstitial Fluid.- Relationship of Intracellular to Extracellular Interstitial Fluid.- Water and Electrolyte Balance.- 8 Acid-Base Disturbances.- Buffering.- Respiratory Control of Acid-Base.- Renal Control of Acid-Base.- Metabolic Control of Acid-Base.- Interpretation of Acid-Base Data.- Respiratory Acidosis.- Respiratory Alkalosis.- Metabolic Acidosis.- Metabolic Alkalosis.- 9 Mechanisms of Haemostasis.- Physiology of Haemostasis.- The Investigation of Haemostatic Disorders.- 10 Cerebral Blood Flow and Metabolism.- Cerebral Blood Flow.- Cerebral Metabolism.- Conclusions.- 11 Defense Strategies Against Hypoxia.- Normal and Abnormal Pasteur Effects.- Oxygen Regulators and Oxygen Conformers.- Metabolite Signals Sustaining Stable Respiration in Oxygen Regulators.- Loss of Standard Electron Transfer System-Glycolysis Integration in Oxygen Conformers.- Oxygen as a Signal Controlling Oxygen Conformity.- Oxygen Management Strategies in Diving Seals.- 12 Humoral and Cell-Mediated Immunity.- The Normal Immune System.- Immunity and Infection.- Pathological Consequences of Immunity.- Immunodeficiency.- 13 Regulation of Body Temperature.- Thermal Equilibrium.- Physiological Measurement of Thermal Strain.- Effects of Heat.- Effects of Cold.- Mathematical Models of Thermoregulation in Man.- Central Nervous Control.- Thermoreception.- Fever.- Effects of Drugs on Thermoregulation.- 14 The Physiology of the Newborn.- Cardio-respiratory Adaptation.- Blood Pressure in the Neonate.- Thermoregulation in the Neonate.- Renal Function.- Neonatal Jaundice.- Pain in the Neonate.- Section B. Cardiovascular Disorders.- 15 Cardiopulmonary Resuscitation.- The Therapeutic Approach to CPR.- The Heart and CPR.- The CNS and CPR.- Monitoring the Brain during CPR.- The Brain After CPR.- Management of Brain Dysfunction and Damage.- Judging the Effectiveness of CPR: Stage 1 Success or Failure.- Pulmonary Function.- Drug Therapy.- Inotropic Agents.- Metabolic Acidosis.- Antidysrhythmic Agents.- Electrolyte Disturbances.- Routes of Drug Administration.- Cannulation of Vessels.- Fluid Expansion.- Artificial Pacemaking.- Abandoning CPR.- Complications of Chest Compression.- Effectiveness of CPR: Stage 2 Success or Failure.- Appendix 1: Mobile Equipment for CPR Trolley.- 16 The Cardiac Dysrhythmias.- Introduction: The Cardiac Rhythm.- Classification of Dysrhythmias.- Mechanisms of Dysrhythmias.- Consequences of Cardiac Dysrhythmias.- Indications for Treatment of Cardiac Dysrhythmias.- Management of Cardiac-Specific Dysrhythmias.- Classification of Anti-arrhythmic Drugs.- Conclusion.- 17 The Pathophysiology of Shock.- History.- Types of Circulatory Shock.- Normal Cardiovascular Homeostasis.- Pathophysiology: Mediators.- Mediators of Circulatory Shock.- Receptors/Middle Messenger Systems.- Shock-Induced Alterations of Metabolism.- Specific Organ Systems.- 18 Management of Shock.- Diagnosis of Shock.- Therapeutic Goals.- Therapy for the Failing Heart.- Management of High Cardiac Output "Distributive" Shock.- Diagnosis and Management of Sepsis.- Role of Steroids in the Management of Shock.- How to Manage the Profoundly Shocked Patient.- 19 Acute Myocardial Infarction.- Emergency Treatment of Evolving Myocardial Infarction.- Early Complications and Their Treatment.- 20 Hypertensive Crisis.- Sodium Nitroprusside.- Nitroglycerin.- Diazoxide.- Hydralazine.- Autonomic Inhibition.- Calcium Channel Antagonists.- Adenosine Compounds.- Conclusion.- 21 Diagnosis and Management of Pulmonary Embolism.- Incidence and Predisposing Factors.- Pathophysiology.- Diagnosis.- Treatment.- Long-term Management and Prognosis.- Prevention.- 22 Postoperative Cardiac Surgical Care.- Low Cardiac Output.- Intra-aortic Balloon Pumping (IABP).- Cardiac Dysrhythmias.- Renal Failure.- Intraoperative Myocardial Injury.- 23 Applied Pharmacology of Cardiovascular Drugs.- Applied Pharmacokinetics.- Antidysrhythmic Agents.- Vasodilator Drugs.- Inotropes and Inotrope Vasodilators.- Diuretics.- Antithrombotic and Thrombolytic Agents.- 24 Congestive Heart Failure: Acute and Chronic.- Definitions.- Epidemiology and Prognosis.- Etiology.- Compensatory Mechanisms.- Characterization.- Diagnosis.- Treatment.- Section C. Respiratory Disorders.- 25 Recovery from Anesthesia.- Purposes of the Post Anesthesia Care Unit.- History of the Recovery Room.- Patient Transfer from Operating Room to PACU.- Admission and Discharge.- Pharmacology of Anesthetic Recovery.- Problems Occurring in the PACU Patient.- Conclusion.- Appendix: Minimal Standards of Care for Post Anesthesia Care Unit Patients.- 26 Airway Management and Mechanical Ventilation During Acute Respiratory Failure.- Airway Management.- Practical Application of Ventilatory Support Systems.- PEEP and F1O2.- Monitoring of Respiratory Function.- Summary.- 27 Overview of Acute Respiratory Failure and the Adult Respiratory Distress Syndrome.- Acute Respiratory Failure.- Adult Respiratory Distress Syndrome.- 28 Pathophysiological Pathways of the Adult Respiratory Distress Syndrome.- Lung Alterations in Early ARF (Hours to Days).- Late Alterations in Severe ARDS (Days to Weeks).- Treatment of ARDS.- 29 Mechanical Ventilation and Weaning.- Physiology of Spontaneous Breathing and Mechanical Ventilation.- Mechanical Ventilation.- Weaning.- 30 Complications of Mechanical Ventilation.- Bronchopulmonary Superinfection.- Damage to Airways and Lung Parenchyma.- Cardiocirculatory Depression.- Impairment of Neurological, Renal and Hepatic Function.- 31 Diagnosis of Pulmonary Infections.- Infections Causing Respiratory Failure.- Infections in Patients Hospitalized with Serious Illness.- 32 Postural Effects on the Acutely Injured Lung.- The Effects of Position on the Healthy Lung.- The Effects of Position During Acute Lung Injury.- Unilateral Lung Disease.- Bilateral Lung Disease.- Section D. Renal, Electrolyte And Metabolic Disorders.- 33 Acute Renal Failure.- Causes of Acute Uraemia.- Clinical Syndromes of ARF.- Thrombotic Microangiopathies.- Diagnosis and Management of ARF.- Investigations.- Management.- Prognosis of ARF.- 34 Fluid and Electrolyte Disorders.- Disorders of Sodium and Fluid Balance: Hyponatraemia and Hypernatraemia.- Hypokalemia and Hyperkalaemia.- Hypocalcaemia and Hypercalcaemia.- Hypophosphataemia and Hyperphosphataemia.- Hypomagnesaemia and Hypermagnesaemia.- Metabolic Disorders of Acid-Base Balance.- 35 Nutritional Failure.- Normal Body Composition.- Starvation and Injury.- Importance of Nutritional Support.- Nutritional Assessment.- Nutritional Support.- Protein Sparing.- Protein and Caloric Requirements.- 36 Optimizing Nutritional Support.- Metabolic Alterations in Critical Illness.- Energy Metabolism.- Nutritional Support.- Techniques of Nutrient Administration.- Nutritional Recommendations.- Organ Dysfunction.- Conclusions..- 37 Acute Hepatic Failure.- and Definitions.- Etiology and Diagnosis.- Clinical Features and Management.- Specific Aspects of Management.- Assessment of Prognosis.- Liver Transplantation.- 38 Postoperative Care Following Hepatic Transplantation.- Immunosuppression.- Function of the Transplanted Liver.- Primary Non-Function of the Transplant.- Treatable Causes of Graft Dysfunction.- Surgical Complications.- Medical Complications.- 39 Acute Pancreatitis.- Etiology.- Pathogenesis.- Diagnosis of Pancreatitis.- Medical Treatment of Acute Pancreatitis.- Surgical Treatment of Pancreatitis.- Attempts to Modify the Early Course of Pancreatitis.- Recommended Surgical Responses to Specific Complications of Acute Pancreatitis.- Persisting Pancreatitis.- 40 Stress Ulceration.- Definition.- Pathology.- Aetiology and Incidence.- Clinical Features and Diagnosis.- Pathogenesis.- Prophylaxis.- Treatment of Acute GI Haemorrhage.- 41 Diarrhoea in the Critically Ill.- Pathophysiology.- Causes of Diarrhoea.- Management.- Conclusion.- Section E. Haematological Disorders.- 42 Disorders of Haemostasis.- Disseminated Intravascular Coagulation.- Liver Disease.- Haemostatic Defects of Uraemia.- Coagulopathy Following Head Injury.- Coagulopathy of Cardiopulmonary Bypass Surgery.- Vitamin K Deficiency in Gastrointestinal Disorders.- Haemostatic Defects Associated with Massive Transfusions.- Complications of Anticoagulant and Thrombolytic Drugs.- 43 The Use of Blood and Blood Products.- The Blood Products: Their Composition, Uses, Administration and Contraindications.- The Use of Blood Products in Rapid Large Volume Transfusions.- Transfusion in the Anaemic Critically Ill Patient.- The Use of Microaggregate Blood Filters.- Fibronectin and Blood Products.- Bedside Checking Routines and Serious Errors in Administering Blood.- Ordering Blood and Blood Products.- 44 Hazards of Blood Transfusion.- Non-infectious Hazards of Blood Transfusion.- Infectious Hazards of Blood Transfusion.- 45 Plasma Substitutes.- Physicochemical Characteristics of Plasma Substitutes.- Natural Colloids.- Artificial Colloids.- Dextrans.- Gelatin.- Hydroxyethyl Starch.- Adverse Effects of Colloidal Plasma Substitutes.- 46 Intensive Care for Patients with Malignant Disease.- Life-Threatening Medical Complications of Malignant Disease.- Infection.- New Pulmonary Infiltrates.- Respiratory Failure.- Haemorrhage.- Metabolic Disturbances.- Cardiovascular Disturbances.- Gastrointestinal Disorders.- Renal Disorders.- Neurological Disorders.- Hyperviscosity Syndrome.- Graft-Versus-Host Disease.- Postoperative Intensive Care.- Prognosis.- Section F. Endocrine Disorders.- 47 Endocrine Emergencies.- Thyroid Gland.- Adrenal Glands.- Pituitary Gland.- Problems in Pregnancy.- Gut Hormones.- Disorders of Mineral Metabolism.- 48 Diabetic Coma.- Crystalloid vs Colloid Infusion.- Intravenous Bicarbonate.- Intravenous Phosphates or Other Supplements.- Anion or Hyperchloraemic Acidosis.- Non-ketotic Hyperglycaemic Coma.- Action List.- Section G. Trauma.- 49 Multiple Injuries.- Definition of Multiple Injury.- Injury Severity Indices.- Early Clinical Considerations in Multiple Trauma Management.- Systemic Effects of Multiple Trauma.- 50 Transporting the Critically Ill.- History 81.- Transport Systems.- Modes of Transport.- Primary Transportation.- Secondary Transportation.- Conclusions.- 51 The Intensive Care of Head-Injured Patients.- General Information.- Structural Pathology.- Cellular and Metabolic Disruption.- Pathophysiology.- Initial Evaluation.- Haematoma.- Disseminated Intravascular Coagulation.- Systemic Hypertension.- Pulmonary Dysfunction.- Ventilation.- Monitoring.- Surgical Decompression.- Pharmacological Control of Intracranial Hypertension.- The Prediction of Outcome.- Is Intensive Care of Head Injuries Worthwhile?.- 52 Acute Cervical Spinal Cord Injury.- Vascular and Rheological Considerations.- Biomechanics.- Physiopathology and Therapy.- Diagnosis.- Critical Care Components of Acute Cervical Cord Trauma.- 53 Chest Trauma.- Blunt Thoracic Trauma.- Penetrating Chest Wounds.- 54 Care of Burns.- Initial Assessment.- Airway Management and Inhalation Injury.- Fluid Resuscitation.- Escharotomy and Fasciotomy.- Wound Closure.- Nutrition.- Bacteriology and Infection.- Complications.- 55 Drowning and Near-Drowning.- Definitions.- History of Drowning.- Epidemiology.- Pathophysiology of Drowning.- Treatment.- Section H. Neurological Disorders.- 56 Coma.- Definitions.- Pathophysiology.- Clinical Examination.- Classification.- Prognosis.- Therapy.- 57 Brain Stem Death.- Historical Background.- Brain Stem Death: Diagnosis.- The Preconditions for Brain Stem Death.- Tests for the Confirmation of Brain Stem Death.- Some Practical Details.- 58 Cerebral Oedema.- Vasogenic Cerebral Oedema.- Cytotoxic Cerebral Oedema.- Hydrostatic Cerebral Oedema.- Hypo-osmotic Oedema.- Congestive Brain Swelling.- Common Problems Associated with Brain Oedema.- Increased Intracranial Pressure.- Clinical Indications of Cerebral Oedema.- Diagnosis of Cerebral Oedema.- Cerebral Oedema and Brain Shift.- Management of Cerebral Oedema and Raised Intracranial Pressure.- Steroid Therapy.- Osmotherapy.- Cerebral Blood Volume Reduction.- Continuous Drainage of Cerebrospinal Fluid.- Conclusions.- 59 Guillain-Barre Syndrome and Myasthenia Gravis.- Guillain-Barre Syndrome.- Myasthenia Gravis.- Lambert-Eaton Myasthenic Syndrome.- Congenital Myasthenic Syndromes.- Neonatal Myasthenia Gravis.- 60 Status Epilepticus and Serial Seizures.- Definition, Limits of the Topic.- Classification and Presentations.- Diagnosis and Pitfalls.- Conditions and Causes.- Mechanisms and Consequences.- Management.- Results and Prognosis.- 61 Psychiatric Problems Associated with Intensive Care.- Patients.- Staff.- Conclusions.- Section I. Acute Poisoning and Disturbances of Temperature Regulation.- 62 The Principles of Management of Acute Poisoning.- Accuracy of Diagnosis.- Toxicological Analysis.- Basic Principles of Medical Treatment.- Elimination of Poisons.- 63 Management of Specific Poisonings.- Psychotropic Drugs.- Cardiotropic Drugs.- Analgesic Agents.- Heavy Metals.- Alcohols and Glycols.- Household Products.- Industrial Intoxicants.- Pesticides.- Drug Addiction.- 64 Accidental Hypothermia.- Aetiology.- Clinical Features.- Pathophysiology.- Management.- Prognosis.- 65 Hyperthermia.- History.- Classification.- Diagnosis of Hyperthermic States.- Fever.- Hyperthermia.- Section J. Infection and Sepsis.- 66 Nosocomial Infections.- Epidemiology.- Specific Problems.- Prevention.- 67 Antibiotic Therapy in the Critically Ill.- Antibiotic Therapy.- Antibiotic Prophylaxis.- Dosage in the Presence of Organ Failure.- Conclusion.- 68 Opportunistic Infection.- Particular Host Defense Defects and Opportunistic Infection.- Epidemiological Aspects of Opportunistic Infection.- Timetable of Infection in Immunosuppressed Patients.- Opportunistic Infections of Particular Importance in the Compromised Host.- Summary.- 69 Intensive Care of Patients with the Acquired Immunodeficiency Syndrome.- Indications for Intensive Care.- Diagnosis of Respiratory Failure in Patients with AIDS.- Therapy for Pulmonary Disorders in AIDS.- Other Indications for Intensive Care.- Outcome of Intensive Care for AIDS Patients with Respiratory Failure.- Making Decisions About Intensive Care for Patients with AIDS.- Infection Control Considerations.- Conclusion.- 70 Tetanus.- F. Vachon.- F. Tremolieres.- D. Robert.- Epidemiology.- Pathogenesis.- Clinical Aspects.- Prognosis.- Complications.- Treatment.- Prevention.- Section K. Methods of Investigation.- 71 Designing in Intensive Care.- Siting.- Size.- Safety.- Accommodation.- Services.- Conclusion.- 72 Bedside Catheterization.- Peripheral Vein Cannulation.- Catheterization of the Central Veins.- Arterial Cannulation.- Pulmonary Artery Catheterization.- Catheterization for Special Purposes.- 73 Techniques for Assessing Respiratory Function in the Critically Ill Patient.- Lung Mechanics.- Gas Monitoring.- Blood Gas Measurement.- Derived Values.- The Future.- 74 Radiology in the Intensive Care Unit.- Technical Principles of Imaging ICU Patients.- Radiography of Monitoring and Support Devices.- Imaging Studies in Acute Respiratory Failure and the Adult Respiratory Distress.- Syndrome.- 75 Nuclear Imaging in Critically Ill Patients.- Adult Respiratory Distress Syndrome.- Pulmonary Embolism and Ventilation-Perfusion Studies.- Computation of Ventilation: Perfusion Ratios in Critically 111 Patients.- Abdominal Surgery.- Sepsis.- Advances in Nuclear Cardiology in Critically 111 Patients.- 76 Severity Scoring and Prediction of Patient Outcome.- Principles of Severity Scoring and Prediction.- Testing for Predictive Accuracy.- The APACHE II System.- Applications.- Future Research Efforts.- Conclusion.- Section L. Paediatric Problems.- 77 Monitoring the Sick Infant.- Temperature.- Electrocardiogram.- Respiration.- Systemic Blood Pressure.- Central Venous Catheters.- Pulmonary Artery Catheters.- Intracranial Pressure.- EEG and Cerebral Function.- 78 Critical Airway Obstruction in Children.- Developmental Anatomy.- Physiology.- History and Physical Examination.- Special Investigations.- Specific Diseases.- Asthma and Status Asthmaticus.- 79 Mechanical Ventilation of the Critically Ill Newborn Child.- Intubation.- Ventilators.- CPAP/PEEP.- Inspiration Time.- Patient-Triggered Ventilation.- High-Frequency Jet Ventilation.- High-Frequency Oscillation.- Continuous Subatmospheric (Negative) Extrathoracic Pressure.- Sedation.- Weaning.- 80 Extracorporeal Membrane Oxygenation in the Newborn.- Respiratory Distress in the Newborn and Indications for Extracorporeal.- Membrane Oxygenation.- Extracorporeal Membrane Oxygenation.- 81 Acute Renal Failure in Infancy and Childhood.- Water and Electrolyte Balance.- Causes of Acute Renal Failure.- Pathophysiology.- Clinical Features.- Diagnosis.- Metabolic Consequences.- Conservative Management.- Dialysis.- 82 Care Following Surgical Treatment of Congenital Heart Disease.- Preoperative Pathophysiology.- Postoperative Assessment and Management.- Special Issues with Specific Malformations.- 83 Treatment of Severe Head Injury in Children.- Pathology.- Therapy.- Conclusions.- 84 Nutritional Problems.- Risk Factors in Childhood Malnutrition.- Appropriate Nutrition.- Nutritional Assessment.- Indications for Parenteral Nutrition.- List of Abbreviations.