Yearbook of Intensive Care and Emergency Medicine 2009

Table of Contents

List of Contributors

Common Abbreviations

I Genomics and Proteomics

Rethinking Sepsis: New Insights from Gene Expression Profiling Studies

Introduction

How to Identify and Measure Heterogeneity

Sources of Heterogeneity in Sepsis Patients

New Insights from Gene-expression Studies

Genomic Heterogeneity

Further Questions on an Existing Sepsis Model

Functional Mapping of Sepsis Genome to Monitor Immune Function

Conclusion

References

Mitochondrial Genetics and Sepsis

Introduction

Oxidative Phosphorylation and ATP Generation

Reactive Oxygen Species

Apoptosis

Mitochondria and Sepsis

Mitochondrial Genetics

Mitochondrial Haplogroups

Conclusion

References

Lung Proteomics in Intensive Care

Introduction

The Search for Biomarkers

Lung Proteomics

Applications in ALI/ARDS

Future Directions

References

II Inflammatory Response

The Host Response to Sepsis

Introduction

Epidemiology and Genetic Variability

Pathogen Recognition Systems

Coagulation and Anticoagulation

Immune Suppression and Apoptosis

HMGB1 and RAGE

The Cholinergic Anti-inflammatory Pathway

Macrophage Migration Inhibitory Factor

C5a and C5a Receptor

Conclusion

References

Endotoxin Tolerance: Mechanisms and Clinical Applicability

Introduction

Mechanisms of Endotoxin Tolerance

Endothelial Function and Microcirculation during LPS Tolerance

Clinical Applicability and Therapeutic Possibilities

Conclusions

References

Oxidative Stress and Endothelial Dysfunction during Sepsis

Introduction

Sources and Actions of ROS and RNS in the Endothelium during Sepsis

Mechanisms of Endothelial Dysfunction during Sepsis

Conclusion

References

Measurement of Carbon Monoxide: From Bench to Bedside

Introduction

Carbon Monoxide Measurement

Carbon Monoxide Concentrations in Critically Ill Patients

Carbon Monoxide Concentrations and Lung Diseases

Carbon Monoxide Concentrations and Other Diseases

Conclusion

References

Monitoring Immune Dysfunction in Septic Patients: Toward Tailored Immunotherapy

Introduction

Monocyte Dysfunction

T Lymphocyte Dysfunction

Conclusion

References

III Current and Future Management of Sepsis

Source Control in the ICU

Introduction

What is ‘Source Control’?

Elements of Source Control

Do we need to perform Source Control?

When to Perform Source Control?

The Role of the Intensivist

What if Source Control is Impossible or Fails?

Special Considerations in Critically Ill Patients

Conclusion

References

IgM-enriched Immunoglobulins in Sepsis

Introduction

Mechanisms of Action of IVIG in Sepsis

Differences between IgG- and IgM-enriched Immunoglobulins

Clinical Significance of IgM-enriched IVIG

Conclusion

References

Clarithromycin: A Promising Immunomodulator in Sepsis

Introduction

Indirect Evidence for an Immunomodulatory effect of Macrolides in Pneumonia

Lessons from Animal Studies

Conclusion

References

High-flow Hemofiltration as an Adjunctive Therapy in Sepsis

Introduction

Mechanism of Action: Hemofiltration as a New Shield against the ‘Chaos Theory’ and ‘Complex Non-linear Systems’ in Sepsis

Recent Animal Trials and Clinical studies Highlighting the Crucial Roles of Dosing and Timing

Practical Aspects for the Bedside Clinician

Future Directions Regarding the Use of Hemofiltration in Sepsis

Conclusion

References

Economic and Social Burden of Severe Sepsis

Introduction

Concepts

Direct Costs of Sepsis Management

Direct Costs of Sepsis Management in Developing Countries: A Brazilian Experience

Indirect Costs and Burden of Illness

Impact of Therapeutic Strategies on Costs

Conclusion

References

IV Proposed Targets for New Therapies

Lymphocyte Apoptosis in Sepsis and Potential Anti-apoptotic Strategies

Introduction

Mechanisms of Apoptosis

Pathways Involved in Apoptosis

Evidence in Animals

Evidence in Humans

Therapeutic Molecular Targets

Conclusion and Perspectives

References

The Pivotal Role of Beta-adrenoreceptors in Critical Illness Pathophysiology

Introduction

New Concepts in Adrenoreceptor Signaling Biology

Desensitization of Beta-adrenoreceptors

Catecholamine-induced Immune Dysregulation

Beta-adrenoreceptor-mediated Metabolic Effects of Critical Illness

Beta-adrenoreceptor-mediated Effects on Barrier Gut Function

Specific Beta-adrenoreceptor-mediated Roles in Common Critical Illness Pathophysiology

Limitations of Current Experimental/clinical Data

Conclusion

References

Non-septic Acute Lung Injury and Inflammation: Role of TLR4

Introduction

Participation of TLR4 in Ischemia-reperfusion Injury

Heme Activates TLR4 by Different Mechanisms than does LPS

Acute Lung Injury Produced by Avian Influenza Virus H5N1 or Acid Aspiration is Dependent on Activation of TLR4 By Oxidized Phospholipids

Fragmented Hyaluronic Acid activates TLR4

TLR4 Participates in Inflammation Associated with Ventilator-induced Lung Injury or Cardiac Hypertrophy Produced by Aortic Stenosis

TLR4 Participates in Late Inflammatory Responses in which HMGB1 Plays a Contributory Role

Heat Shock Proteins (HSP) Induce Pro-inflammatory Cytokine Release through TLR4

TLR4 Participates in Ethanol-induced Inflammation

Acetaminophen-induced Liver Injury is TLR4-dependent

Conclusion

References

Hydrogen Sulfide: A Metabolic Modulator and a Protective Agent in Animal Models of Reperfusion Injury

Introduction

The Biological Chemistry of Hydrogen Sulfide

H2S as an Inducer of a State Resembling Suspended Animation

Protective Effects of H2S in Local or Whole-body Ischemia or Ischemia-reperfusion

Conclusion

References

V Septic Shock

‘Myocardial Depression’ or ‘Septic Cardiomyopathy’?

Introduction

Septic Cardiomyopathy: A Secondary Cardiomyopathy in the Scope of the Systemic Disease, ‘Sepsis’

How to Quantify Septic Cardiomyopathy?

Septic Cardiomyopathy is of Prognostic Relevance

Septic Cardiomyopathy: Triggers and Mechanisms

Causal Approaches towards the Treatment of Acute Septic Cardiomyopathy

Conclusion

References

Determinants of Tissue PCO2 in Shock and Sepsis: Relationship to the Microcirculation

Introduction

Mechanisms of Increase in Venous and Tissue PCO2: The Basics

Intramucosal Acidosis in Sepsis

References

Refining the Tools for Early Goal-directed Therapy in Septic Shock

Introduction: Initial Management of Septic Shock

Overview of Early Goal-directed Therapy

Therapeutic Steps and Goals and Proposed Refinements

Other Issues

Conclusion

References

VI Intravenous Fluids

Hyperchloremic Metabolic Acidosis: More than Just a Simple Dilutional Effect

Introduction

Mechanisms Underpinning pH Regulation: A Physico-chemical Approach

Effects of Plasma Volume Expansion on pH

Clinical Consequences of Hyperchloremic Metabolic Acidosis

Conclusion

References

Old versus New Starches: What do We Know about their Differences?

Introduction

Hydroxyethyl Starch Pharmacokinetics

Volume Effects

Renal Effects

Coagulation and Bleeding

Tissue Storage

Pruritus

Long-term Survival

Conclusion

References

Impact of Hydroxyethyl Starch on Renal Function

Introduction

Pharmacokinetic Profile of HES Solutions

Pathomechanisms of HES-induced Renal Dysfunction

Clinical Evidence of HES-induced Renal Dysfunction

Conclusion

References

Rational Approach to Fluid Therapy in Acute Diabetic Ketoacidosis

Introduction

Historical Perspective

Pathophysiology

Aims of Fluid Therapy

Optimal Management

Conclusion

References

VII Hemodynamic Support

Cardiac Filling Volumes and Pressures in Assessing Preload Responsiveness during Fluid Challenges

Introduction

Goals and Effects of Fluid Loading: Defining Preload and Fluid Responsiveness

Filling Pressures and Volumes of the Heart

Physiological Considerations and Clinical Implications

Conclusion

References

Update on Preload Indexes: More Volume than Pressure

Introduction

Filling Pressures (CVP and PAOP)

Continuous Right Ventricular End-diastolic Volume (cRVEDV)

Global-end Diastolic Volume and Intrathoracic Blood Volume

Conclusion

References

Monitoring Arterial Blood Pressure and Cardiac Output using Central or Peripheral Arterial Pressure Waveforms

Introduction

Wave Contour in the Central and Peripheral Arteries

Agreement between Central and Peripheral Blood Pressure in Specific Clinical Situations

Influence of the Site of Blood Pressure Measurement on Continuous Cardiac Output Estimation

Conclusion

References

Intrathoracic Pressure Regulation for the Treatment of Hypotension

Introduction

Active Intrathoracic Pressure Regulation Therapy for Apneic Hypotension Patients

Intrathoracic Pressure Regulation Therapy and CPR

Intrathoracic Pressure Regulation Therapy and Survival Outcomes in Hemorrhagic Shock

Intrathoracic Pressure Regulation Therapy and Sepsis

Potential Adverse Consequences and Limitations of Intrathoracic Pressure Regulation Therapy

Conclusion

References

Functional Hemodynamic Monitoring: A Personal Perspective

Introduction

Use of Dynamic Responses to Identify Nascent Cardiovascular States

Preload Responsiveness

Cardiovascular Sufficiency

Future Trends

References

VIII Airway Management

Endotracheal Intubation in the ICU

Introduction

Care Management Bundle to Increase the Safety of Endotracheal Intubation in the ICU

Conclusion

References

Pediatric Advanced Airway Management Training for Non-anesthesia Residents

Introduction

Risks associated with Tracheal Intubation and Provider Competence

Demand for Pediatric Airway Management Competence in Pediatric Resident Trainees

Process of Acquisition and Retention of Pediatric Tracheal Intubation Competence

Future Directions

Conclusion

References

Automatic Tube Compensation in the Weaning Process

Introduction

Automatic Tube Compensation

Commercially available Automatic Tube Compensation Systems

Potential Clinical Uses of Automatic Tube Compensation

Practical Aspects of using Automatic Tube Compensation

Conclusion

References

IX Mechanical Ventilation

Extracorporeal Membrane Oxygenation for Cardiac and Pulmonary Indications: Improving Patient Safety

Introduction

Application of ECMO Today

Further Development of ECMO

Control and Safety

References

Patient-ventilator Interaction during Non-invasive Ventilation

Introduction

NIV in Acute Respiratory Failure

Triggering of the Ventilator

Pressurization Slope

Level of Pressure Support

Cycling

Masks

Conclusion

References

Variable Mechanical Ventilation: Breaking the Monotony

Introduction

Patterns of Variability and their Characterization

Rationale for the Use of Variable Patterns in Mechanical Ventilation

History of Variable Mechanical Ventilation

Variable Controlled Mechanical Ventilation

Variable Assisted Mechanical Ventilation

Why does Respiratory Function Improve during Variable Mechanical Ventilation?

Is Variable Mechanical Ventilation Equivalent to Regular Ventilation with Intermittent Sighs?

Can Variable Mechanical Ventilation be Injurious?

Limitations of Variable Mechanical Ventilation

Conclusion

References

Life-threatening Asthma: Focus on Lung Protection

Introduction

Epidemiology

Definitions

Risk Factors

Pathophysiology of the Acute Asthma Attack

Therapeutic Approach

Conclusion

References

X Respiratory Monitoring

Bedside Monitoring of Diaphragm Electrical Activity during Mechanical Ventilation

Introduction and Background

Bedside Monitoring of EAdi

Conclusion

References

Electrical Impedance Tomography

Introduction

How Electrical Impedance Tomography Works

Clinical Applications

Potential Future Applications of Clinical Relevance

Conclusion

References

Regional Ventilation Delay Index: Detection of Tidal Recruitment using Electrical Impedance Tomography

Introduction

Individual PEEP Setting is Essential

Global and Regional Lung Function Parameters

Elecrical Impedance Tomography

The Concept of the Regional Ventilation Delay Index

Implementing Regional Ventilation Delay Index in Clinical Practice

Conclusion

References

Different Approaches to the Analysis of Volumetric Capnography

Introduction

Capnography: Types and Applications

Techniques for Volumetric Capnography Analysis

A New Algorithm for Volumetric Capnography Analysis

Conclusion

References

Variation in Extravascular Lung Water in ALI/ARDS Patients using Open Lung Strategy

Introduction

Measurement of EVLW at the Bedside

EVLW in ALI/ARDS Patients

Ventilation Strategy in ALI/ARDS and EVLW Variations

Conclusion

References

Clinical Utility of Extravascular Lung Water Measurements

Introduction

Measurement of EVLW

Limitations of the Measurement of EVLW by Transpulmonary Dilution Techniques

Clinical Utility of EVLW

Conclusion

References

XI Perioperative Management

Rationalizing the Use of Surgical Critical Care: The Role of Cardiopulmonary Exercise Testing

Introduction

Why Use Cardiopulmonary Exercise Testing as an Assessment Tool?

Which Patients should Undergo Cardiopulmonary Exercise Testing?

Cardiopulmonary Exercise Testing in Practice

Interpretation of Cardiopulmonary Exercise Test Data

Risk Stratification and Management using Cardiopulmonary Exercise Testing

Case Reports

Conclusion

References

Advanced Minimally Invasive Hemodynamic Monitoring of the High-risk Major Surgery Patient

Introduction

Definition and Role of Perioperative Optimization

Overview of Some Current Advanced Hemodynamic Monitors

Decline in Use of Central Venous Catheterization for Major Surgery

Conclusion

References

Post-pneumonectomy Pulmonary Edema

Introduction

Diagnostic Criteria

Prevalence

Pathology

Etiology

Conclusion

References

The Role of Phenylephrine in Perioperative Medicine

Role of the Calcium Sensitizer, Levosimendan, in Perioperative Intensive Care Medicine

Inhaled Nitric Oxide Therapy in Adult Cardiac Surgery

XII Cardiac Function

Use of Natriuretic Peptides in the Emergency Department and the ICU

Abnormalities of the ST Segment

Functional Mitral Regurgitation in the Critically Ill

XIII Cardiopulmonary Resuscitation

Feedback to Improve the Quality of CPR

The Post-cardiac Arrest Syndrome

Use of a Standardized Treatment Protocol for Post-cardiac Resuscitation Care

Therapeutic Hypothermia after Cardiac Arrest

XIV Renal Function

Biomarkers of Acute Kidney Injury in Critical Illness

The Role of Biomarkers in Cardiac Surgeryassociated Acute Kidney Injury

Neutrophil Gelatinase-associated Lipocalin: An Emerging Biomarker for Angina Renalis

XV Hepatosplanchnic Function

How does Intra-abdominal Pressure Affect the Daily Management of My Patients?

ICG Clearance Monitoring in ICU Patients

Acute-on-Chronic Liver Failure in Cirrhosis: Defining and Managing Organ Dysfunction

XVI Nutrition

The Curse of Overfeeding and the Blight of Underfeeding

Enteral Feeding during Circulatory Failure: Myths and Reality

Enteral Nutrition with Anti-inflammatory Lipids in ALI/ARDS

Glutamine Supplementation in ICU Patients

XVII Glucose Control

Burn Causes Prolonged Insulin Resistance and Hyperglycemia

Glucose Variability in Critically Ill Patients

XVIII Adrenal Function

Corticosteroid Biology in Critical Illness: Modulatory Mechanisms and Clinical Implications

Corticosteroid Treatment of Patients in Septic Shock

XIX Coagulation

New Anticoagulants: Anti-IIa or Anti-Xa Agents?

Emergency Reversal of Anticoagulants

XX Neurological Aspects

The Role of Imaging in Acute Brain Injury

Monitoring and Managing Raised Intracranial Pressure after Traumatic Brain Injury

Sepsis-associated Encephalopathy

XXI Malignancies

Acute Tumor Lysis Syndrome: Diagnosis and Management

Life-threatening Neurological Complications in Patients with Malignancies

Should We Admit Critically Ill Cancer Patients to the ICU?

XXII Drug Dosing

Optimizing Drug Dosing in the ICU

Relevant CYP450-mediated Drug Interactions in the ICU

XXIII Sedation and Analgesia

Sedation and Pain Management in the ICU

The Role of Dexmedetomidine in Intensive Care

Monitoring Delirium in the ICU

XXIV ICU Management

Intensive Care for the Elderly: Current and Future Concerns

ICU Performance: Managing with Balanced Scorecards

XXV End-of-Life Issues

Managing Conflict at the End-of-Life

Strengths and Weaknesses of Substitute Decision Making in the ICU

Subject Index