Yearbook of Intensive Care and Emergency Medicine 2010

Title Page

Copyright Page

Table of Contents

List of Contributors

Common Abbreviations

I The Microcirculation

The Microcirculation and Oxidative Stress

Introduction

Reactive Oxygen Species

Sources of ROS in the Microcirculation

Mitochondria

NADPH Oxidase

NO Synthase

Xanthine Oxidase

Other Sources of Superoxide Anion Production

Interactions of ROS with the Microcirculation

Leukocyte-endothelial Cell Adhesion

Vascular Tone Regulation

The Vast Spectrum of Intracellular Targets for ROS

Role of Oxidative Stress in Microcirculatory Dysfunction

Ischemia-reperfusion

Sepsis

Conclusion

References

Diagnosis and Treatment of the Septic Microcirculation

Introduction

Normal Microcirculation

The Microcirculation in Sepsis

Bedside Study of the Microcirculation

The Microcirculation in Distributive Shock

Recruiting the Microcirculation Network During Distributive Shock

Conclusion

References

Targeted Treatment of Microvascular Dysfunction

Introduction: Microvascular dysfunction is the Root Cause of Inflammatory Organ Dysfunction

Traditional Therapies and Biomarkers have Centered on the Macrocirculation

New Methods of Assessing the Microcirculation

Therapeutic Approaches

Suppression of Intracellular Inflammatory Signaling

Other inhibitors of cellular inflammation

Suppression of Circulating Mediators of Inflammation

Large scale removal by hemofiltration

Intravenous immunoglobulin

Neutralizing antibodies

Coagulation

Conclusion

References

II Hemodynamic Monitoring

Diagnosing Hypovolemia in Critically Ill Patients

Introduction

Defining Hypovolemia

Diagnosing Hypovolemia

Static Diagnostic Tests

Dynamic Diagnostic Tests

Fluid challenge

Arterial waveform-derived variables

Passive leg raising

Perspective

Conclusion

References

Measuring Stroke Volume Using Electrical Impedance Tomography

Introduction

Why do we need Non-invasive Cardiovascular Measurements?

Electrical Impedance Tomography

EIT-based Methods to Measure Stroke Volume

Holding the Breath

EKG Gating

Optimized Separation in the Temporal and Spatial Domains

Contrast Agents

Deriving Stroke Volume from Cardiac Impedance Images

Impedance-time Curves

Parametric EIT

Conclusion

References

Direct Arterial Pressure Monitoring: Pattern Recognition in the Management of Circulatory Failure

Introduction

Case Study 1: Components of an Arterial Pressure Waveform

Case Study 2: Hypovolemia

Case Study 3: Pulse Pressure as a Measure of Stroke Volume

Case Study 4: Effect of Aortic Capacitance on Pulse Pressure

Case Study 5: Effect of Vasoconstrictor Drugs on Pulse Pressure

Case Study 6: Effect of Vasoconstriction on the Dicrotic Notch and Secondary Pressure Waves

Case Study 7: Sympathetic Stimulation and Reflected Pressure Waves

Conclusion

References

Choosing Patient-tailored Hemodynamic Monitoring

Introduction

What Do We Have and What Can they Do?

Factors Affecting Choices

Conclusions and Perspective

References

III Resuscitation Issues

Airway and Ventilation during CPR

Introduction

Regurgitation and Aspiration after Cardiac Arrest

The Pros and Cons of Tracheal Intubation

Advantages of Tracheal Intubation

Disadvantages of Tracheal Intubation

Reducing the Risk of Unrecognized Esophageal Intubation

Supraglottic Airway Devices

Ventilation during CPR

Passive Oxygen Insufflation

Mouth-to-mouth Ventilation

Conclusion

References

The Role of Gasping in Resuscitation

Introduction

The Frequency of Gasping in Global Ischemic Events

The Meaning of Gasping in Global Ischemic Events

The Unique Physiology of Sudden Circulatory Collapse

Gasping as an Independent Factor for Improving Survival

Improved Airflow, Blood Flow, or Both?

Using Gasps to Avoid the Detriments of Positive Pressure Breaths

Better Detection of Cardiac Arrest Using Gasps

The Role of Gasping in Trauma Care and Infant Resuscitation

Creating Gasps for Those Who Do Not Do So

Conclusion

References

Recent Concepts in Burn Resuscitation

Introduction

Resuscitation Perspectives

Can Metabolic Markers Guide Resuscitation and Help Predict Outcomes?

Military Resuscitation Experience (Tables 1 and 2)

Nurse-driven Resuscitation

Consensus Statements

Conclusion

References

Intra-aortic Balloon Counterpulsation in Cardiogenic Shock

Introduction

What do the Guidelines tell Us and What about ‘Real Life’?

Does Hemodynamic Improvement Improve Prognosis in Infarction-triggered Cardiogenic Shock?

Effects of IABP on Hemodynamics, Systemic Inflammation and MOF in Infarction-triggered Cardiogenic Shock

What Does a Meta-Analysis Tell Us?

Beyond IABP: Do We Have Better Alternatives for the Treatment of Cardiogenic Shock?

Impella® Pump

Extracorporeal Membrane Oxygenation (ECMO)

Tandem Heart®

Assisted Extracorporeal Life-support in Adults with In-hospital Cardiac Arrest

IABP versus Percutaneous LVAD in Cardiogenic Shock: A Meta-analysis

We Should Change the Guidelines for IABP Use in Infarction-triggered Cardiogenic Shock!

Intra-aortic Balloon Counterpulsation in Septic Shock?

Conclusion

References

IV Inflammatory Responses in the Lung

Vascular Endothelial Growth Factor in Acute Lung Injury

Introduction

Biology of VEGF

VEGF Receptors

Cellular Source of VEGF within the Lung

Cellular Actions of VEGF

VEGF as a Pathophysiological Driver of Acute Lung Injury?

VEGF Compartmentalization in Acute Lung Injury

Tissue Studies

Regulation of VEGF Bioactivity

Is there a Unifying Hypothesis for the Role of VEGF in Acute Lung Injury?

Conclusion

References

Role of CD14 in Lung Inflammation and Infection

Introduction

CD14 and the LPS Receptor Complex

CD14 and other Pattern Recognition Receptors

Role of CD14 in LPS- and LTA-induced Lung Inflammation

Role of CD14 in Lung Infection

Conclusion

References

V Mechanical Ventilation

Measurement of Functional Residual Capacity during Mechanical Ventilation

Introduction

Methods for FRC Measurement During Mechanical Ventilation

Closed Circuit Techniques

Open Circuit Wash-in/washout Procedures

Respiratory Inductive Plethysmography

Computed Tomography Scan

Conclusion

References

New and Conventional Strategies for Lung Recruitment in Acute Respiratory Distress Syndrome

Introduction

Definition and Factors Affecting Recruitment Maneuvers

Nature and Extent of Lung Injury

Patient Positioning

Types of Recruitment Maneuver

Impact of Recruitment Maneuver on Ventilator-induced Lung Injury

The Role of Variable Ventilation as a Recruitment Maneuver

Conclusion

References

Consequences of Pleural Effusions for Respiratory Mechanics in Ventilated Patients

Introduction

Origin of Pleural Effusions in the Critically Ill Patient

Modeling the Pleural Effusion-lung Interaction

Pleural Effusion and Respiratory Mechanics

Effects of Pleural Effusion on Gas Exchange

Practical Implications for the Mechanically Ventilated Patient with Pleural Effusion

Pleural Effusions and Ventilator-induced Lung Injury?

Conclusion

References

Weaning Failure of Cardiac Origin: Recent Advances

Introduction

Mechanisms Contributing to the Development of Weaning-induced Pulmonary Edema

Diagnosis of Weaning-induced Pulmonary Edema

Clinical Context

Right Heart Catheterization

Transthoracic Echocardiography

Cardiac Biomarkers

Detection of Weaning-induced Hemoconcentration

Therapeutic Options

Conclusion

References

VI Respiratory Failure

The Effects of Pleural Effusion

Introduction

Pathogenesis

Effects of Acute Pleural Effusion on Lung Volume, Respiratory System Mechanics, and Gas Exchange

Effects of Thoracentesis on Lung Volume, Respiratory System Mechanics, and Gas Exchange

Pleural Effusion in Patients with ALI/ARDS

Conclusion

References

Fluid Management in Acute Lung Injury and ARDS

Introduction

The Consequences of Pulmonary Edema during ARDS

ARDS: Lesional or Hemodynamic Edema?

Resorption and Drainage of Pulmonary Edema

Fluid Restriction and Diuretics: Clinical Studies and Practical Consequences

Modulation of Oncotic or Osmotic Pressure: The Effects of Administering Albumin or Hypertonic Saline

Increasing Resorption of Alveolar Edema – A Complementary Objective

Conclusion

References

Life-threatening Respiratory Failure from H1N1 Influenza: Lessons from the Southern Cone Outbreak

Introduction

Why was Pandemic (H1N1) 2009 Flu So Prevalent in the Southern Cone?

How Big was the Outbreak?

Common Complications of Influenza

Risk Factors for the Acquisition of Severe H1N1 2009 Primary Influenza Pneumonia

Differences Comparing this Pandemic with the usual Seasonal Flu

Management

Non-pharmacologic Therapy

Ventilatory settings

Recruitment maneuvers

Prone position ventilation

Adjunctive therapies to mechanical ventilation

Pharmacologic Therapy

Antivirals

Antibacterial antimicrobials

Corticosteroid therapy

Complications

Bacterial Infection

Pulmonary Embolism

Extrapulmonary Manifestations

Renal Failure

Cryptogenic Organizing Pneumonia

Prognostic Factors for Fatal Influenza Pneumonia

Preventive Measures

Conclusion

References

VII Infections

Cytomegalovirus Infections in Non-immunocompromised Critically Ill Patients

Introduction

Clinical Studies

Conclusion

References

Prevention of Central Venous Catheter-related Infection in the Intensive Care Unit

Introduction

Catheter Care Protocols

Staff Educational/Quality Improvement Program

Type of Catheter

Catheter Insertion Site

Ultrasound-guided Placement

Insertion Technique

Skin Antisepsis

Antibiotic Prophylaxis

Tunneling

Dressing

Venous Line Maintenance

Conclusion

References

Standardization of Care to Improve Outcomes of Patients with Ventilator-associated Pneumonia and Severe Sepsis

Introduction

Prevention and Treatment of VAP

Severe Sepsis and Septic Shock

Conclusion

References

Strategies for Implementation of Evidence-based Guidelines for Prevention of Healthcare-associated Infection

Introduction

Guidelines

Adherence to Guidelines

Barriers

Facilitators

Theories of Change

Implementation Research

Implementation Interventions and Strategies

Short Historical Overview

The 1990s

The 2000s

Current insights

Implementation of Infection Prevention Guidelines

Interventional studies

Systematic review

Evaluating the Implementation

Cost Considerations

Conclusion

References

Antibiotic Stewardship: Possibilities when Resources Are Limited

Introduction

STEP 1-Include the Antibiotic Stewardship Program within the Hospital Infection Control Program

STEP 2-Be Aware of the Different Antibiotic Stewardship Program Strategies

STEP 3-Define the Core Strategy/Key Antibiotics/Areas to Include within the Antibiotic Stewardship Program According to the Institution’s Resources

STEP 4-Develop and Define Institution-adapted Antibiotic Stewardship Program Performance Indicators

Conclusion

References

VIII Metabolic Support

Vitamin D in Critical Illness

Introduction

Historical Perspective

Circadian Rhythm of Vitamin D

Pleiotropic Effects of Vitamin D

Vitamin D and the Musculoskeletal System

Vitamin D and Cardiovascular Disease

Vitamin D and the Immune System

Vitamin D and Sepsis

Miscellaneous Effects of Vitamin D

Vitamin D in Critical Illness

Challenges for the Intensivist

References

IX Anticoagulant Therapies

Update on Antithrombin for the Treatment of Burn Trauma and Smoke Inhalation Injury

Introduction

Antithrombin

Therapeutic Effects of Antithrombin

Anticoagulant Effects

Anti-inflammatory effects dependent on the coagulation system

Coagulation-independent anti-inflammatory effects

Interactions with Heparin

Antithrombin for the Treatment of Burn Trauma and Smoke Inhalation Injury

Experimental Studies

Clinical Studies

Conclusion

References

Update on Physiological Anticoagulant Factor Concentrates in Patients with Sepsis

Introduction

Inflammation-induced Effects on Physiological Anticoagulant Factors

The Antithrombin System

The Thrombomodulin-protein C System

Tissue Factor Pathway Inhibitor

Effects of Natural Anticoagulant Systems on Inflammation

Clinical Application of Natural Anticoagulant Factor Concentrates

Antithrombin Concentrate

Recombinant Human Activated Protein C

Soluble Thrombomodulin

Recombinant Tissue Factor Pathway Inhibitor

Conclusion

References

X Anemia and Blood Transfusions

Venous Oxygen Saturation as a Physiologic Transfusion Trigger

Introduction

Venous Oxygen Saturation as a Physiologic Transfusion Trigger

The Concept of Physiologic Transfusion Trigger

Conclusion

References

Tissue Protective Activities of Erythropoietin

Introduction

EPO and Tissue Protection

Tissue Protection and Clinical Trials

Erythropoiesis versus Tissue Protection

Conclusion

References

XI Renal Disease and Therapy

Doppler-Based Renal Resistive Index: A Comprehensive Review

Introduction

Technique

Physiological Significance of the Renal Resistive Index

Doppler-Based Renal Resistive Index in Selected Renal Diseases

Non-obstructive Renal Diseases

Obstructive Renal Diseases

A Promising Tool in Critically Ill Patients?

Conclusion

References

Atrial Natriuretic Peptide in Postoperative Acute Renal Failure

Introduction

The Discovery of the Atrial Natriuretic Peptide System

Renal Effects of ANP in Humans

Renal Blood Flow

Glomerular Filtration Rate

Tubular Effects of ANP

Effects of ANP on Renal Oxygen Consumption

Effects of ANP on Renal Blood Flow and GFR in Postoperative Acute Renal Failure

Effects of ANP on Renal Outcome in Acute Renal Failure

Effects of ANP in Other Forms of Clinical Acute Renal Failure

Cyclosporine-induced Acute Renal failure

Liver Transplantation

Radiocontrast-induced Nephropathy

Meta-Analysis of ANP in the Management of Acute Renal Dysfunction

Conclusion

References

Renal Dysfunction in Chronic Liver Disease

Introduction

Co-existing Liver and Kidney Disease

Serum Creatinine Concentration for the Assessment of Kidney Function in Chronic Liver Disease

Acute Kidney Injury Network Criteria for staging Acute Kidney Injury

Acute Kidney Injury Pathogenesis

Patients with Chronic Liver Disease are more Susceptible to Acute Kidney Injury

Hepatorenal Syndrome

Acute Kidney Injury and Chronic Liver Disease

Biomarkers of AKI

Kidney Disease Outcome Quality Initiative Criteria for Staging Chronic Kidney Disease

Assessment of Chronic Kidney Disease in Patients with Chronic Liver Disease

Future Directions

Orthotopic Liver Transplantation

Conclusion

References

Hemofiltration and Hybrid Therapies in 2010

Introduction

Mechanisms of Removal and Transport by Synergistic Action of HVHF and Enhanced Adsorption

Synergistic action of HVHF and Enhanced Adsorption: Clinical Feasibility and Effects beyond Hemodynamics

New Pathophysiological Insight regarding Septic Acute Kidney Injury

Update on Very Recent Trials in Critically ill Patients with AKI

Conclusion

References

Timing of Renal Replacement Therapy

Introduction

AKI: An Historical Overview

A Problem of Uremia

The Concept of Prophylactic Dialysis

From Acute Renal Failure to AKI, and from Renal Replacement Therapy to Renal Support: A Paradigm Shift

Definition of Timing of Initiation of RRT in ICU Patients

What does the Evidence tell Us?

Urea

Volume overload

Early initiation in the course of AKI

Future Directions: Early Goal-directed Therapy to Improve Renal Outcome

Conclusion

References

XII Neurological Aspects

Multimodal Monitoring: A Critical Tool in the Neuro-ICU

Introduction

Multimodal Monitoring in Hypoxic-Ischemic Encephalopathy

Multimodal Monitoring in Traumatic Brain Injury

Multi-modal Monitoring in Cerebrovascular Disease

Conclusion

References

Hemodynamic Management of Acute Spinal Cord Injury

Introduction

Overview of the Incidence and Pathophysiology of Acute Traumatic Spinal Cord Injury-induced Cardiovascular Dysfunction

Blood Pressure Augmentation in Patients with Acute Traumatic Spinal Cord Injury

Spinal Cord Perfusion Pressure, Intrathecal Pressure, and Treatment

Potential Risks of Blood Pressure Augmentation in Acute Spinal Cord Injury

Conclusion

References

Quantitative CT Scan and CT-Estimated Brain Specific Gravity in TBI

Introduction

Quantitative Computed Tomography

Quantative CT Study of Non-contused Hemispheric Areas

Quantitative CT Study of Contused Hemispheric Areas

Interpretation of Estimated Specific Gravity Variation

Conclusion

References

Cerebral Perfusion in Sepsis

Introduction

Sepsis and the Brain

Inflammation and the Brain

Effects of Sepsis on the Blood-brain Barrier and the Vascular Endothelium

Cerebral Perfusion

Cerebral Perfusion Pressure

Regulation of Cerebral Perfusion

CO2-reactivity

Cerebrovascular pressure autoregulation

Perfusion and Brain Dysfunction

Cerebral ischemia

Cerebral perfusion and sepsis-associated delirium

Effects of catecholamines on cerebral perfusion in patients with sepsis

Conclusion

References

Systemic Complications after Subarachnoid Hemorrhage

Introduction

Cardiac Abnormalities

Lung Abnormalities

Fever

Anemia

Hyperglycemia

Electrolyte Abnormalities

Conclusions

References

XIII Perioperative Management

Epidural Anesthesia: New Indications for an Old Technique?

Introduction

Effects of Epidural Anesthesia on Pain Management

Effects of Thoracic Epidural Anesthesia on Myocardial Function

Effects of Thoracic Epidural Anesthesia on Pulmonary Function

Effects of Thoracic Epidural Anesthesia on Gastrointestinal Function

Effects of Thoracic Epidural Anesthesia on the Immune System

Effects of Thoracic Epidural Anesthesia on Long-term Outcome

Adverse Effects and Potential Risks of Epidural Anesthesia

Conclusion

References

Risk Assessment and Prevention of Perioperative Stroke

Introduction

Pathophysiology

Review of Clinical Studies

Preventive Strategies

Conclusion: Proposed/useful Clinical Perioperative Guidelines

References

Overview of Chronic Post-thoracotomy Pain: Etiology and Treatment

Introduction

Prevalence

Pathology

Preoperative Factors

Demographic Factors

Genetics

Psychosocial Factors

Preoperative Pain

Intraoperative Factors

Surgery

Analgesia

Postoperative Factors

Others

Strategies for Treating Long Term Pain

Conclusion

References

XIV Abdominal Compartment Syndrome

The Polycompartment Syndrome: What’s all the Fuss About?

Introduction

Pathophysiology

Orbital Compartment Syndrome

Intracranial Compartment Syndrome

Thoracic Compartment Syndrome

Cardiac Compartment Syndrome

Limb or Extremity Compartment Syndrome

Hepatic Compartment Syndrome

Renal Compartment Syndrome

Pelvic Compartment Syndrome

Abdominal Compartment Syndrome

Monitoring of intra-abdominal pressure

Abdominal perfusion pressure measurement

Clinical Management

Conclusion

References

Laparostomy: Why and When?

Introduction

Who Started Laparostomy?

Temporary Abdominal Cover

Classification of Open Abdomen

Definitive Abdominal Wall Closure

Does Laparostomy Improve Outcome?

Conclusion

References

XV Drug Distribution and Clearance

Augmented Renal Clearance: Unraveling the Mystery of Elevated Antibiotic Clearance

Introduction

Defining Augmented Renal Clearance

Assessing Renal Function in Critical Illness

Changes in Critical Illness Contributing to Augmented Renal Clearance

Prevalence and Natural History of Augmented Renal Clearance in the Critically Ill

Traumatic Brain Injury

Surgery and Trauma

Burns

Hematological Malignancy

Hypoalbuminemia

What are the Clinical and Dosing Implications of Augmented Renal Clearance?

Concentration-dependent Killing

Aminoglycosides

Time-dependent Killing

ß-lactam antibiotics

Oxazolidinone antibiotics

AUC0–24/MIC antibiotics

Glycopeptides

Quinolone antibiotics

Therapeutic Drug Monitoring

Conclusion

References

Drug Distribution: Is it a more Important Determinant of Drug Dosing than Clearance?

Introduction

Overview of Pharmacokinetic and Pharmacokinetic/pharmacodynamic Parameters

Volume of Distribution versus Clearance: How do they Affect Serum Drug Concentration and Half-life?

Causes and Consequences of Increased Volume of Distribution

Chronic Increases in Volume of Distribution

Obesity

Chronic organ dysfunctions

Other scenarios

Acute Increases in Volume of Distribution

Severe sepsis

Burns

Hypoalbuminemia

Other scenarios

Measurement of Volume of Distribution in Critically Ill Patients

Clinical Significance and Recommended Dose Strategies

Conclusion

References

XVI Risk Stratification

Risk Stratification in Severe Sepsis: Organ Failure Scores, PIRO or Both?

Introduction

Organ Dysfunction/Failure Scores

From Multiple Organ Dysfunction/Failure Scores to the PIRO Concept

Should We Have One PIRO Or Many PIROs?

Should we use PIRO or MOF Scores?

References

XVII Critical Care Outreach

On the Response to Acutely Deteriorating Patients

Introduction: The Deteriorating Patient

Sub-optimal Care

‘Track and Trigger’ Mechanisms

Role of Critical Care Outreach Services

Educational Tools

Use of Technology as a Tool to ‘Track and Trigger’

Human Factors

Conclusion

References

Identifying Cardiorespiratory Insufficiency Outside the ICU

Introduction

Existing Non-invasive Cardiovascular Monitoring is Ineffective at Identifying Instability In Step-down Units

Integrated Monitoring Systems to Monitor the Monitors

Implications

References

XVIII End-of-life Issues

An Update on ICU Management of the Potential Organ Donor

Introduction

Role of the Intensivist

Physiologic Changes Associated with Brainstem Death

Protocols for Management of the Potential Organ Donor

Management of Individual Organ Systems

Cardiovascular

Pulmonary

Endocrine

Renal and Gastrointestinal

Coagulopathy and Hypothermia

Donation after Cardiac Death

Conclusion

References

End-of-life Care in the ICU: Commonalities and Differences between North America and Europe

Introduction

Discrepancy between Preferred and Actual Place of Death

Use of Critical Care Services during Terminal Hospitalization

Health Care Costs during Terminal Hospitalization

Variation in End-of-life Intensive Care Use

End-of-life Decision-making Process

An American Perspective

A European Perspective

Unintended Consequences of End-of-life Decision-making

Conclusion

References

XIX Patient Care

Do Sleep Disorders have an Impact on Outcome in ICU Patients?

Introduction

Anesthesia/sedation and Sleep are not Identical, but may Share Common Mechanisms

Exploring Sleep in ICU Patients

Characteristics of Sleep Alteration in ICU Patients

ICU Environment

Mechanical Ventilation

Drugs

Impact of Sleep Disturbance on Patient Outcome

Therapeutic Interventions to Preserve/improve Sleep (Table 2)

Attenuation of Noise and Light

Limiting Interventions

Changing to Assist-control or Proportional Assist Ventilatory Modes

Use of Pharmacological Interventions

Conclusion

References

Communication in Crisis: The Importance of ‘Verbal Dexterity’

Introduction

The Importance of Communication and Culture

Airway, Breathing, Communication: The New ABCs of Crisis Management

“Say what you Mean, and Mean what you Say”

Mitigating Speech: “No ifs, and, or Buts”

Silence is not always Golden

Graded Assertiveness: Getting the Message Across

Questioning Authority and Handing Over Responsibility: Underappreciated Skills

Practicing Verbal Dexterity

Managing Interruptions and Distractions

Communication really Ought to have Three Cs

Conclusion

References

Patient Safety and Acute Care Medicine: Lessons for the Future, Insights from the Past

Introduction

‘The Missing Curriculum’ [3]

Engineering and Acute Care Medicine

Engineering and Error Prevention

Understanding the Basics of Human Error

Educating for Safety

Maximizing the Best of Human and Machine

Other Lessons from the Chessboard

Conclusion

References

Subject Index