bluuebunny/crossref_metadata_2025 huggingface dataset:
The metabolic and nutritional response to critical illness
Authors: Mottram Linda-Jayne , Lavery Gavin G.
Published: April 2016

The metabolic response to critical illness is complex and affects every body system. The first phase of this response is characterized by increased hypothalamic pituitary activity and resistance (decreased response) to effector hormones in many target tissues. Cytokines released in the early stages of such illness may be important as they appear to stimulate the hypothalamic pituitary axis directly as part of this ‘stress response’. This phase is considered ‘adaptive’ (helpful), increasing the availability of glucose, free fatty acids, and amino acids as substrates for vital organs. However, in prolonged illness, the neuroendocrine response is very different with damped hypothalamic responses, leading to a state in which catabolism predominates, leading to what might be termed the critical illness wasting syndrome. The gastrointestinal (GI) failure often associated with prolonged critical illness appears to be due, at least in part, to an altered neuroendocrine environment. The poor nutritional state associated with GI failure exacerbates the catabolic response, prolonging illness and the period of intensive care management required by the patient. The result is increased mortality and, in survivors, a more prolonged recovery/rehabilitation process.
Pathophysiology of nutritional failure in the critically ill
Authors: Wernerman Jan
Published: April 2016

Nutritional and metabolic care makes a difference in critical illness. Optimal nutrition can improve outcomes and complications with nutrition may do harm. The energy needs of critically-ill patients are controversial, and it is important to discriminate between this initial phase of critical illness and a more stable phase evolving into rehabilitation. Indirect calorimetry is very helpful to optimize the energy supply. It is repeatedly suggested that protein supply to critically-ill patients should be higher than to healthy individuals. There is, however, little evidence for this proposal, although it is a part of most guidelines. To consider nutritional failure, optimal nutrition should be defined. In critical illness more mechanistic research is needed to define optimal nutrition and metabolic care.
Assessing nutritional status in the ICU
Authors: Egreteau Pierre-Yves , Boles Jean-Michel
Published: April 2016

Decreased nutrient intake, increased body requirements, and/or altered nutrient utilization are frequently combined in critically-ill patients. The initial nutritional status and the extent of the disease-related catabolism are the main risk factors for nutrition- related complications. Many complications are related to protein energy malnutrition, which is frequent in the ICU setting. Assessing nutritional status pursues several different goals. Nutritional assessment is required for patients presenting with clinical evidence of malnutrition, with chronic diseases, with acute conditions accompanied by a high catabolic rate, and elderly patients. Recording the patient’s history, nutrient intake, and physical examination, and subjective global assessment allows classification of nutritional status. All the traditional markers of malnutrition, anthropometric measurements and plasma proteins, lose their specificity in the sick adult as each may be affected by a number of non-nutritional factors. Muscle function evaluated by hand-grip strength in cooperative patients and serum albumin provide an objective risk assessment. Several nutritional indices have been validated in specific groups of patients to identify patients at risk of nutritionally-mediated complications and, therefore, the need for nutritional support. A strong suspicion remains the best way of uncovering potentially harmful nutritional deficiencies.
Enteral nutrition in the ICU
Authors: Lev Shaul , Singer Pierre
Published: April 2016

Enteral nutrition (EN) is an integral part of the patient care in the intensive care unit (ICU) in order to maintain gut integrity, to modulate stress and the systemic immune response, and to attenuate disease severity. The timing of commencing EN in critically-ill patients depends on patient status and should be initiated as soon as the patient is stabilized. The energy and protein targets should be estimated and the feed prescription should match the nutritional target. The rate of EN dose increment or the addition of supplemental parenteral nutrition (PN) to reach the nutritional target is still debatable and ranges between 3 days (ESPEN approach) and up to 8 days (ASPEN approach). Micronutrients should be supplemented to all patients. The role of pharmaconutrition is controversial due to recent negative trials, but the use of EN with supplemental omega-3 and GLA for acute respiratory distress syndrome patients is still advocated by ESPEN and ASPEN guidelines.
Parenteral nutrition in the ICU
Authors: Cohen Jonathan , Lev Shaul
Published: April 2016

Parenteral nutrition (PN) is a technique of artificial nutrition support, which consists of the intravenous administration of macronutrients, micronutrients, and water. PN has become integrated into intensive care unit (ICU) patient management with the aim of preventing energy deficits and preserving lean body mass. The addition of PN to enteral nutrition is known as supplemental PN. Parenteral feeding should be considered whenever enteral nutritional support is contraindicated, or when enteral nutrition alone is unable to meet energy and nutrient requirements. International guidelines differ considerably regarding the indications for PN. Thus, the ESPEN guidelines recommend initiating PN in critically-ill patients who do not meet caloric goals within 2–3 days of commencing EN, while the Canadian guidelines recommend PN only after extensive attempts to feed with EN have failed. The ASPEN guidelines advocate administering PN after 8 days of attempting EN unsuccessfully. Several studies have demonstrated that parenteral glutamine supplementation may improve outcome, and the ESPEN guidelines give a grade A recommendation to the use of glutamine in critically-ill patients who receive PN. Studies on IV omega-3 fatty acids have yielded promising results in animal models of acute respiratory distress syndrome and proved superior to solutions with omega -6 compositions. The discrepancy between animal models and clinical practice could be related to different time frames.
Normal physiology of the renal system
Authors: Cooper Bruce Andrew
Published: April 2016

Patients with critical illness often have renal dysfunction, either primary or secondary, that can both complicate and prolong their medical management. Therefore, an understanding of normal renal physiology can help recognize the process or processes that caused the renal dysfunction, and determine the most appropriate corrective and supportive care. The kidney has many important roles other than just urine production. The impact of kidney disease is often predictable. The kidney plays a critical role in fluid and electrolyte balance via many specialized transmembrane pathways. The kidney is also involved in the production and modification of two key hormones and one enzyme. Understanding normal renal physiology can help determine clinical management.This chapter summarizes the important aspects of renal physiology relevant to those who work in a critical care environment.
Diagnosis of oliguria and acute kidney injury
Authors: Kellum John A.
Published: April 2016

Diagnosis and classification of acute pathology in the kidney is major clinical problem. Azotemia and oliguria represent not only disease, but also normal responses of the kidney to extracellular volume depletion or a decreased renal blood flow. Clinicians routinely make inferences about both the presence of renal dysfunction and its cause. Pure prerenal physiology is unusual in hospitalized patients and its effects are not necessary benign. Sepsismay alter renal function without the characteristic changes in urine indices. The clinical syndrome known as acute tubular necrosis does not actually manifest the histological changes that the name implies. Acute kidney injury (AKI) is a term proposed to encompass the entire spectrum of the syndrome from minor changes in renal function to a requirement for renal replacement therapy. Criteria based on both changes in serum creatinine and urine output represent a broad international consensus for diagnosing and staging AKI.
The effect of chronic renal failure on critical illness
Authors: Kinsella Sinead , Holian John
Published: April 2016

The incidence of chronic kidney disease (CKD) and end-stage kidney disease (ESKD) is increasing, reflecting an increase in the incidence and prevalence of hypertension and type 2 diabetes. Patients with CKD and ESKD frequently experience episodes of critical illness and require treatment in an intensive care unit (ICU)setting. Management requires specific consideration of their renal disease status together with their acute illness. Mortality in critically-ill patients with ESKD is frequently related to their co-morbid conditions, rather than their ESKD status. Illness severity scoring systems allocate high points for renal variables and tend to overestimate actual mortality. Patients with ESKD and CKD requiring ICU admission have better ICU and in-hospital survival than patients with denovo acute kidney injury requiring renal replacement therapy. Appropriately selected patients benefit from ICU admission and full consideration for ICU care should be given to these patients if required, despite their renal disease status. Cardiovascular disease and sepsis account for the majority of ICU admissions in this population and the aetiology of these conditions differs from that in patients without kidney disease. Optimal critical care management of patients with ESKD and CKD requires that these differences are recognized.
Electroencephalogram monitoring in the critically ill
Authors: Vespa Paul M.
Published: April 2016

Electroencephalography monitoring provides a method for monitoring brain function, which can complement other forms of monitoring, such as monitoring of intracranial pressure and derived parameters, such as cerebral perfusion pressure. Continuous electroencephalogram (EEG) monitoring can be helpful in seizure detection after brain injury and coma. Seizures can be detected by visual inspection of the raw EEG and/or processed EEG data. Treatment of status epilepticus can be improved by rapid identification and abolition of seizures using continuous EEG. Quantitative EEG can also be used to detect brain ischaemia and seizures, to monitor sedation and aid prognosis.
Cerebral blood flow and perfusion monitoring in the critically ill
Authors: Gaddam Samson Sujit Kumar , Robertson Claudia S.
Published: April 2016

Prevention of secondary cerebral ischaemic insults is an important management strategy in acute neurological conditions. Monitoring of cerebral perfusion may aid in early identification of ischaemic insults and help with management. A number of tools are available for this purpose. Cerebral perfusion pressure (CPP) is the simplest assessment of cerebral perfusion, but in some cases ischaemia can be present even with a normal CPP. Cerebral blood flow (CBF) imaging, either with computed tomography or magnetic resonance imaging techniques, can provide quantitative regional CBF measurement, but only at a single instance in time. Such studies are valuable in the diagnosis of ischaemia, but are difficult for the management of critically-ill patients. CBF can also be measured within the intensive care unit (ICU), either directly or indirectly through the measurement of cerebral oxygenation. These monitors provide a more continuous measure of CBF, and are more useful in assessing response to treatment. Some of the ICU tools monitor global perfusion and some assess perfusion only in a local area of brain surrounding the monitor. With local monitors, the location of the probe is important for interpretation of the findings.
Pathophysiology and causes of seizures
Authors: Bleck Thomas P.
Published: April 2016

Seizures result from imbalances between excitation and inhibition, and between neuronal synchrony and dyssynchrony. Current models implicate the cerebral cortex in the genesis of seizures, although thalamic mechanisms (particularly the thalamic reticular formation) are involved in the synchronization of cortical neurons. Often, the precipitants of a seizure in the critical care setting are pharmacological. Several mechanisms linked to critical illness can lead to seizures. Failure to remove glutamate and potassium from the extracellular space, functions performed predominantly by astrocytes, occurs in trauma, hypoxia, ischaemia, and hypoglycaemia. Loss of normal inhibition occurs during withdrawal from alcohol and other hypnosedative agents, or in the presence of GABA. Conditions such as cerebral trauma, haemorrhages, abscesses, and neoplasms all produce physical distortions of the adjacent neurons, astrocytes, and the extracellular space. Deposition of iron in the cortex from the breakdown of haemoglobin appears particularly epileptogenic. Although acute metabolic disturbances can commonly produce seizures in critically-ill patients, an underlying and potentially treatable structural lesion must always be considered and excluded.
Assessment and management of seizures in the critically ill
Authors: Bleck Thomas P.
Published: April 2016

In previously conscious patients seizures are usually easily detected. Critically-ill patients are frequently sedated and a proportion are paralysed with neuromuscular blocking agents, in such patients it may be hard or impossible to detect seizures clinically. An urgent electroencephalogram (EEG) should be obtained whenever seizures are witness or suspected, especially if the patient does not rapidly return to baseline, when non-convulsive status epilepticus must be excluded. Unless the cause of the seizure activity is already known, an urgent CT, or MRI is indicated. If central nervous system infection is suspected a lumbar puncture may be needed. Status epilepticus is diagnosed when there is recurrent or continued seizure activity without intervening recovery. Most seizures are self-limiting and stop after 1–2 minutes, seizures that continue for more than 5 minutes should be treated. Treatment priorities for any seizure are to stop the patient hurting either themselves or anyone else. General supportive measures include attention to the airway, breathing, circulation, exclusion of hypoglycaemia and an EEG to exclude non-convulsive status epilepticus. A variety of drugs can be used to terminate seizures; parenteral benzodiazepines are the most commonly used agents although propofol and barbiturates are alternatives. Emergent endotracheal intubation may well be necessary, hypotension can be expected and may need treatment with intravenous fluids and vasopressors.
Epidemiology of stroke
Authors: Delcourt Candice , Anderson Craig
Published: April 2016

Approximately 20 million strokes occur in the world each year and over one-quarter of these are fatal. This makes stroke the second most common cause of death, after ischaemic heart disease, and strokes are responsible for 6 million deaths (almost 10% of all deaths) annually. Stroke has major consequences in terms of residual physical disability, depression, dementia, epilepsy, and carer burden. Moreover, around 20% of survivors experience a further stroke or serious vascular event within a few years of the index event. The economic and societal costs of stroke are enormous. With ongoing demographic changes, including the ageing and urbanization of populations, and persistence of highly prevalent risk factors related to adverse lifestyles, the global burden of disease related to stroke is predicted to rise substantially by 2030.
Management of ischaemic stroke
Authors: Patarroyo Sully Xiomara Fuentes , Anderson Craig
Published: April 2016

Ischaemic stroke is the most common cause of stroke around the world. It is a complex disease with a range of causes, manifestations, outcomes, and treatments. As the therapeutic time window to rescue or ‘protect’ the brain from ischaemic damage is extremely short, effective treatment requires coordinated systems of care, which commence in the prehospital paramedical setting and continue through the emergency department into the critical care environment, neurology ward, rehabilitation, and re-settlement back home. Successful outcomes from ischaemic stroke can be achieved through the effective use of thrombolytic therapy to re-canalize an occluded vessel and re-perfuse the ‘at risk’ area of the brain. Other aspects of management include the prevention of complications of the neurological (cerebral) disability, timely introduction of rehabilitation, realistic goal-setting towards satisfactory recovery, and secondary prevention measures to reduce the high risk of recurrent stroke and other serious vascular events.
Disorders of magnesium in the critically ill
Authors: Esen Figen
Published: April 2016

Plasma potassium levels are maintained in health between 3.5 and 5.0 mmol/L, and reflect total body potassium only in stable states at normal pH. Most true hyperkalaemia results from renal insufficiency. The goals of therapy are myocardial protection and return of plasma potassium to a safe level. Measures are commonly initiated above 5.5 mmol/L; above 6.5 mmol/L, aggressive measures should be adopted and calcium salts given if there are cardiac dysrhythmias or QRS-broadening. Glucose-insulin infusions and beta-2-agonists promote potassium shifts into cells. Diuretics and sodium bicarbonate may be helpful, but persistent hyperkalaemia is an indication for renal replacement therapy. Hypokalaemia may lead to dangerous arrhythmias, skeletal muscle weakness, ileus, and reduced vascular smooth muscle contractility. Rapid replacement should only be undertaken for severe hypokalaemia or in the context of arrhythmias. Once the extracellular deficit is corrected, there will usually be a continuing need for potassium supplementation to replenish intracellular stores.
The blood cells and blood count
Authors: Albert Tyler J. , Swenson Erik R.
Published: April 2016

Blood is a dynamic fluid consisting of cellular and plasma components undergoing constant regeneration and recycling. Like most physiological systems, the concentrations of these components are tightly regulated within narrow limits under normal conditions. In the critically-ill population, however, haematological abnormalities frequently occur and are largely due to non-haematological single- or multiple-organ pathology. Haematopoiesis originates from the pluripotent stem cell, which undergoes replication, proliferation, and differentiation, giving rise to cells of the erythroid, myeloid, and lymphoid series, as well as megakaryocytes, the precursors to platelets. The haemostatic system is responsible for maintaining blood fluidity and, at the same time, prevents blood loss by initiating rapid, localized, and appropriate blood clotting at sites of vascular damage. This system is complex, comprising both cellular and plasma elements, i.e. platelets, coagulation and fibrinolytic cascades, the natural intrinsic and extrinsic pathways of anticoagulation, and the vascular endothelium. A rapid, reliable, and inexpensive method of examining haematological disorders is the peripheral blood smear, which allows practitioners to assess the functional status of the bone marrow during cytopenic states. Red blood cells, which are primarily concerned with oxygen and carbon dioxide transport, have a normal lifespan of only 120 days and require constant erythropoiesis. White blood cells represent a summation of several circulating cell types, each deriving from the hematopoietic stem cell, together forming the critical components of both the innate and adaptive immune systems. Platelets are integral to haemostasis, and also aid our inflammatory and immune responses, help maintain vascular integrity, and contribute to wound healing.
Assessment and management of dermatological problems in the critically ill
Authors: Groves Richard
Published: April 2016

Although dermatology is generally considered to be an outpatient specialty relating to conditions of low acuity, a wide array of skin problems can present in the critically-ill patient. Some may reflect pre-existing disease, some may occur as a consequence of treatment, and a small fraction will represent severe or extensive primary skin disease that is best managed in a critical care setting. Important primary dermatological conditions that require intensive care management include erythroderma, toxic epidermal necrolysis/Stevens–Johnson syndrome, widespread drug eruptions and blistering disorders with extensive skin involvement. All patients with extensive skin disease will require expert nursing care in order to mitigate the consequences of skin failure. Thus, low-friction beds, non-adherent primary dressings, careful attention to the prevention of infection, temperature regulation, fluid management, and so on are critical. Life-threatening skin disease requires a carefully coordinated multidisciplinary approach involving dermatologists, intensivists, organ specialists, and specialist nurses to improve long-term outcome.
Rheumatoid arthritis in the critically ill
Authors: Cartin-Ceba Rodrigo , Prakash Udaya B. S.
Published: April 2016

Rheumatoid arthritis is a progressive chronic inflammatory disease of autoimmune aetiology, characterized by joint swelling, tenderness, and destruction of synovial joints, leading to severe disability and premature mortality. The prevalence of rheumatoid arthritis has been estimated at 0.5–1% of the adult population and is the most common form of inflammatory joint disease. Rheumatoid arthritis frequently affects many non-articular systems, most commonly the cardiopulmonary, gastrointestinal, and haematological systems. Over recent years, the optimal use of disease-modifying anti-rheumatic drugs, in particular methotrexate, and the availability of several new biological agents, have dramatically enhanced the success of rheumatoid arthritis management. Multiple studies have demonstrated the efficacy of anti-TNF therapy, as well as other targeting, in reducing inflammatory activity, as well as inhibiting joint destruction in patients with active rheumatoid arthritis. A significant number of patients admitted to the intensive care unit (ICU) with autoimmune conditions have rheumatoid arthritis. The studies evaluating the outcome of rheumatoid arthritis patients admitted to the ICU have included other rheumatological conditions, but all have identified a high mortality (17–55%).
Dressing techniques for wounds in the critically ill
Authors: Kleinpell Ruth , Crawford Laura
Published: April 2016

The use of dressings may be indicated in the management of wounds and pressure ulcers, and is dependent on many factors, including the intended purpose of the dressing. The aetiology or cause of the wound will directly impact on the choice of dressing, as factors such as whether a pressure ulcer has undermining and requires packing to fill dead space need to be considered. Other considerations related to aetiology include whether exudates management and compression are required as is the case with venous insufficiency, or whether moisture is preferred, as is often the case with arterial ulcers. The appropriate selection of dressings for pressure ulcers can facilitate healing, although there is insufficient evidence to indicate which specific dressings are the most effective. This chapter reviews important considerations in the use of dressings for wounds and pressure ulcers. In managing the critically-ill patient, knowledge of the indications for use of currently available wound care products and dressings is important for critical care clinicians and consultation with a wound care specialist is recommended.
Other tropical diseases in the ICU
Authors: Dondorp Arjen M.
Published: April 2016

A wide range of tropical infectious diseases can cause critical illness. Knowledge of the local epidemiology where the disease is acquired is essential. In addition, local resistance patterns of common bacterial pathogens can be very different in tropical countries, so that antibiotic regimens might need adaptation. The ‘surviving sepsis’ guidelines are not always appropriate for the treatment of tropical sepsis. Both diseases require a more restricted fluid management. Leptospirosis is another important tropical disease that can cause sepsis with liver and renal failure or ARDS with pulmonary haemorrhages. Neglected tropical diseases causing neurological syndromes include trypanosomiasis (Sub-Saharan Africa) and rabies. Several viruses in the tropics can cause encephalitis. Recent epidemics of respiratory viruses causing life-threatening pneumonia have had their origins in tropical countries, including severe acute respiratory syndrome, influenza A subtype H5N1 (‘avian influenza’), and recently Middle East respiratory syndrome coronavirus.
Management of sepsis in the critically ill
Authors: Sevransky Jon
Published: April 2016

Sepsis is triggered by an infection, and treatment of sepsis requires timely identification of the patient, and rapid treatment with antibiotics, source control, and fluids. The site of infection, patient’s phenotype, and location of the patient will help drive decisions about initial antibiotic therapy. Patients with sepsis should be treated to ensure adequate cardiac output and organ perfusion, which usually requires infusion of intravenous fluids. In addition to haemodynamic and fluid support, some patients require infection source control. Many sepsis patients require additional supportive therapy with vasoactive agents, mechanical ventilation, renal replacement therapy, and nutritional therapy.. When using these supportive therapies, the clinician should attempt to minimize the complications of the therapies, including withdrawal of therapies that are no longer necessary.. Patients who do not respond to initial therapy should be evaluated for resistant organisms, persistent sources, or alternate diagnoses.
Cardiac injury biomarkers in the critically ill
Authors: McLean Anthony S. , Huang Stephen J.
Published: April 2016

To be clinically relevant, a good cardiac biomarker should have four main characteristics. It should be organ-, disease- and stage-specific to be useful in diagnosis. Its release should be timely and its half-life should be long enough to make measurement possible and meaningful. Its serum or blood concentration should be proportional to disease severity; hence, can be used as a monitoring tool. Finally, their concentrations have implications on long-term outcomes. To date, only a handful of cardiac biomarkers have clinical relevance in the intensive care setting—cardiac troponins (as a marker of cardiac injury) and B-type natriuretic peptide (as a marker of cardiac stress) being probably the most useful. However, cautious interpretations of these biomarkers are needed in intensive care patients as several confounding factors can affect their concentrations.
Coagulation and the endothelium in acute injury in the critically ill
Authors: Levi Marcel , van der Poll Tom
Published: April 2016

Vascular endothelial cells play a pivotal mediatory role in many responses to systemic inflammation, including the cross-talk between coagulation and inflammation in sepsis. Endothelial cells respond to the cytokines expressed and released by activated leukocytes, but can also release cytokines themselves. Furthermore, endothelial cells are able to express adhesion molecules and growth factors that may not only promote the inflammatory response further, but also affect a myriad of downstream responses. It has recently become clear that, in addition to these mostly indirect effects of the endothelium, injured endothelial cells directly interfere with platelet-vessel wall interactions, neutrophil entrapment through formation of extracellular nets, and activation of inflammation and coagulation mediated by microparticles. The role of the glycocalyx as an important interface between the endothelium and regulation of coagulation in inflammatory states has also gained a lot of recent attention.
Pathophysiology and management of anaphylaxis in the critically ill
Authors: Keegan James , Deakin Charles D.
Published: April 2016

Anaphylaxis is a severe life-threatening systemic hypersensitivity reaction, which occurs in approximately 10–20 per 100,000 population per annum, and accounts for 0.3% of adult critical care admissions. Anaphylaxis most commonly results from an exaggerated immune reaction to foreign antigens, prompting release of vasoactive substances from mast cells. A broad range of agents including foods, insect stings, latex, and drugs can trigger anaphylaxis. Common food allergens include nuts, shellfish, milk, and eggs. The most frequently implicated drugs include neuromuscular blocking agents (NMBAs) and antibiotics. The clinical features of anaphylaxis are variable and may occur together or in isolation. Epinephrine is the primary treatment for anaphylaxis, administered via the intramuscular route. Measurement of mast cell tryptase is essential for the diagnosis of anaphylaxis. Samples should be taken immediately, at 1–2 hours, and at 24 hours after the onset of symptoms. Investigations should be directed at identification of the trigger agent, and patients should be provided with information to enable them to avoid probable triggers and recognize future episodes.
Role of toxicology assessment in poisoning
Authors: Jaeger Albert
Published: April 2016

Diagnosis of acute poisoning is based on history, symptoms, biomedical investigations, toxicological analyses, and sometimes therapeutic tests. Toxicological analytical methods are now widely available. A qualitative or semiquantitative analysis of the parent compound may be adequate for diagnostic assessment. A quantitative analysis is mandatory for kinetic studies. For instance, in ethylene glycol poisoning, analysis of ethylene glycol concentrations is useful for the diagnosis, but glycolate concentrations are more relevant for the evaluation of the severity and prognosis. Groups of symptoms (or toxidromes) may provide diagnostic clues for toxins that are not usually included in routine screening. The management of the poisoned patient is mostly supportive, but toxicological quantitative analyses are mandatory for some treatments, e.g. alkaline diuresis in salicylate poisoning, repeated activated charcoal in theophylline poisoning, haemodialysis, ethanol in ethylene glycol poisoning, or the use of chelating agents.
Management of salicylate poisoning
Authors: Farmer Brenna M. , Flomenbaum Neal
Published: April 2016

Salicylates are weak acids that work as neurotoxins. The goal of management is to keep salicylates out of the brain and enhance elimination. Acute salicylate toxicity manifests as tinnitus, nausea, vomiting, and hyperventilation in a patient who takes a single large ingestion. Chronic salicylate toxicity is associated with long-term use, has a more insidious onset, and symptoms tend to be less severe, resulting in delayed diagnosis. It is more commonly seen in elderly patients. Therapeutic interventions for toxicity include gastrointestinal decontamination, serum and urine alkalinization, and haemodialysis. Mechanical ventilation may lead to clinical deterioration and death in a salicylate-poisoned patient due to worsening acidosis from respiratory failure. This results in severe acidosis, cerebral oedema, pulmonary oedema, and cardiac arrest.
Management of poisoning by amphetamine or ecstasy
Authors: Freye Enno
Published: April 2016

While amphetamine and especially methamphetamine (speed) is being misused by all social classes in order to increase stamina, intellectual expansion, endurance, and euphoria, the drug 3,4-methylenedioxy-N-methylamphetamine (MDMA) (ecstasy) is preferentially abused by the younger generation for the feeling of empathy, the touching within, and enhancement of the senses. Acute intoxication differs in regard to their effects on the person. The predominant sympathetic overstimulation after methamphetamine results in cardiovascular and CNS hyperactivity accompanied by agitation and seizures, while tachycardia is a prodrome of fibrillation. The excess hypertonia often leads into myocardial infarction and may even induce cerebral haemorrhage. MDMA intoxication often seen in the emergency department is predominantly characterized by hyperthermia, the most important condition to treat, followed by rhabdomyolysis and acute renal failure. Since there is no specific antidote available, in both cases therapy consists of treatment until the acute effects are gone.
Management of digoxin poisoning
Authors: Lapostolle Frédéric , Borron Stephen W.
Published: April 2016

Despite a gradual decline in the clinical use of digitalis glycosides, digitalis toxicity continues to be responsible for substantial morbidity and mortality, particularly among the elderly. Digitalis poisoning may occur acutely, after intentional overdose, but is more often seen as the result of chronic intoxication among patients receiving digitalis therapy. Clinical findings in chronic digitalis poisoning are often subtle. The astute clinician will enquire about digitalis use in older patients with vague complaints and will not be dissuaded from considering digitalis toxicity in the face of a ‘therapeutic’ digitalis blood concentration. Two digitalis preparations continue to be used with frequency, depending on geography. Digoxin is the digitalis glycoside of choice in the USA, while digitoxin prevails in some parts of Europe. While the methods and half-lives of elimination differ markedly for these two substances, the approach to poisoning by either is similar. Advanced age, underlying cardiovascular disease, and severe hyperkalaemia represent poor prognostic factors in digitalis poisoning. Early administration of digitalis Fab fragments should be undertaken when life-threatening symptoms are present. Prophylactic therapy with reduced doses of Fab fragments should be strongly considered for less serious toxicity.
Management of carbon monoxide poisoning
Authors: Annane Djillali , Aboab B. Jérôme
Published: April 2016

CO poisoning is the commonest cause of toxic death. Carbon monoxide is colourless, odourless, and tasteless, and is produced under various conditions. When people inhale CO, the gas diffuses rapidly to the body and replaces oxygen at the level of haemoglobin, myoglobin, and other oxygen carriers. Subsequently, CO causes oxygen deprivation of all body tissues. CO also induces oxidative stress and systemic inflammation. After CO poisoning a broad variety of symptoms may occur. Survivors of CO poisoning often present with persistent neurological sequels or develop delayed neurological symptoms. There is poor correlation between carboxyhaemoglobin levels and clinical symptoms. The presence of coma, underlying co-morbid conditions and need for mechanical ventilation are the main prognostic factors. Management includes prompt extraction from the toxic environment and breathing 100% oxygen, although the role and practicalities of hyperbaric oxygen therapy remain controversial.
Pathophysiology and management of electrocution
Authors: Neiger Jeffrey S. , Trohman Richard G.
Published: April 2016

Electrocution is a common source of morbidity and mortality, primarily affecting young children through accidents in the home and adults through occupational exposure. A familiarity with the basic principles of electrical physics helps elucidate the typical injuries sustained following electrical shock. Although death is a frequent result, patients successfully resuscitated following initial cardiopulmonary arrest often have a favourable prognosis. Survivors of electrocution may suffer injuries to a variety of organ systems, including the skin, cardiovascular system, and nervous system, and are generally treated in specialized burn units. Such patients are considered trauma patients, and should be treated accordingly. Determination of prognosis is often difficult, because the full extent of injury from electric shock is not always initially apparent.
Pathophysiology and management of hyperthermia
Authors: Bouchama Abderrezak
Published: April 2016

Hyperthermia is a state of elevated core temperature that rises rapidly above 40°C, secondary to failure of thermoregulation. Hyperthermia has many causes, but it is the hallmark of three conditions—heatstroke, malignant hyperthermia, and neuroleptic malignant syndrome. The clinical and metabolic alterations of hyperthermia, if left untreated, can culminate in multiple organ system failure and death. High temperature causes direct cellular death and tissue damage. The extent of tissue injury is a function of the degree and duration of hyperthermia. Heat-induced ischaemia-reperfusion injury, and exacerbated activation of inflammation and coagulation are also contributory. Hyperthermia is a true medical emergency with rapid progression to multiple organ system failure and death. The primary therapeutic goal is to reduce body temperature as quickly as possible using physical cooling methods, and if indicated, the use of pharmacological treatment to accelerate cooling. There is no evidence of the superiority of one cooling technique over another. Non-invasive techniques that are easy to use and well-tolerated are preferred. Pharmacological cooling with Dantrolene sodium is crucial in the treatment of malignant hyperthermia.
Management of sedation in the critically ill
Authors: Patel Bhakti K. , Kress John P.
Published: April 2016

Once adequate analgesia is confirmed, the need for sedation should be considered. Sedation of mechanically-ventilated patients is a common challenge in the intensive care unit (ICU). Metabolism of sedatives in critical illness can be unpredictable and achieving optimal sedation without coma is a moving target. Once adequate analgesia is achieved, the choice, depth, and duration of sedation can have major implications for the presence of delirium, the duration of mechanical ventilation, ventilator-associated pneumonia, and ICU length of stay. Therefore, goal-directed titration of sedative and frequent assessment of the depth of sedation is important to strike the delicate balance of patient comfort, while avoiding excessive prolonged sedation.
Identification of the high-risk surgical patient
Authors: Pearse Rupert , James Stephen
Published: April 2016

The low overall post-operative mortality rate conceals the existence of a sub-group of high-risk patients, which accounts for over 80% of post-operative deaths. Age, co-morbid disease, limited functional capacity, and an emergency presentation for major surgery are hallmarks risk. The magnitude, duration, and consequences of post-operative morbidity are determined by a complex interplay between the indication for surgery, the resulting tissue injury, and patient factors. A number of methods including risk scoring and cardiopulmonary exercise testing can be used to identify the high-risk group. Efforts should be made throughout the peri-operative period to prevent the occurrence of any post-operative complications, as they all carry significant long-term implications.
Obstetric physiology and special considerations in ICU
Authors: Neligan Patrick J. , Laffey John G.
Published: April 2016

Pregnant patients constitute less than 1% of intensive care unit admissions, and fewer than 1% of obstetric patients become critically ill. Critical illness may result from pregnancy-specific diseases, diseases that pregnancy predisposes to, or are co-incidental to pregnancy. The presence of a second patient—the foetus—may necessitate adjustments to therapeutic and supportive strategies. However, the foetus is generally robust despite maternal illness. The physiological changes of pregnancy are significant, but may delay the diagnosis of critical illness, requiring modifications to standard management approaches. These include increases in minute ventilation, resulting in a ‘low normal’ PaCO2, a reduction in mean arterial pressure, but increased heart rate, low serum creatinine, relative hypoglycaemia, relative leukocytosis, and reduced lower oesophageal sphincter tone. Pre-eclampsia is a disease of the uteroplacental unit that results in abnormal maternal physiology. Pregnant women are at risk for acute respiratory distress syndrome, due to gastropulmonary aspiration and increased risk of community-acquired pneumonia, sepsis, principally of the genito-urinary system, and thromboembolic disease.
Intensive care management in cardiac transplantation
Authors: Rajagopal Keshava , Griffith Bartley P.
Published: April 2016

Cardiac transplant recipients are among the most complex critically-ill patients in the peri-transplant phase. In this chapter, a comprehensive multi-organ system review of heart transplant recipient management is undertaken, after a brief summary of the pre-implantation donor organ management and the conduct of the transplantation procedures themselves. Specific issues addressed that are unique to the transplant recipient include technical complications, primary allograft dysfunction, and hyperacute and acute allograft rejection. Since issues in heart and lung transplantation are reviewed separately, heart–lung transplantation is not discussed as an independent topic.
ICU selection and outcome of patients with haematological malignancy
Authors: Townsend William M. , Morris Emma C.
Published: April 2016

Patients with haematological malignancies require admission to the intensive care unit (ICU) due to the underlying disease, as a consequence of treatment with chemotherapy or after haematopoietic stem cell transplantation. With an increasing numbers of patients being diagnosed with these diseases and longer survival as treatments improve, the burden on ICU is anticipated to increase. There is compelling evidence that patients should not be denied admission to ICU based on the presence of a haematological malignancy. In this chapter the disease- and treatment-related reasons for ICU admission, outcome, and risk prediction scores for patients with haematological malignancies are discussed.
Management of the bone marrow transplant recipient in ICU
Authors: Retter Andrew
Published: April 2016

Bone marrow transplants are an exciting and rapidly evolving area of haematology providing life-saving therapy to many patients and the number performed annually is increasing. Transplants are generally not considered as first line therapy due to their inherent toxicity and high rate of complications. The patients tend to have more heavily pre-treated disease with it attendant toxicities and a decreased physiological reserve. Admission rates vary between series from 15 to 30%. It is increasingly important that intensivists are aware of the basic principles of bone marrow transplantation and its’ possible morbidities. There are two types of transplant autologous transplants, where the patient’s own stem cells are returned to them and transplants from a donor. Only allogeneic transplants are associated with graft-versus-host disease. Allograft recipients also require immunosuppression to prevent transplant rejection. It is essential that this immunosuppression is continued when patients are admitted to intensive care. Transplant patients are always severely immunocompromised and prone to prolonged periods of neutropenia. They routinely receive antiviral, antifungal, and antibacterial prophylaxis, which must be continued on their admission. They remain vulnerable to unusual infections presenting in an atypical fashion. It is essential to have both a very low clinical threshold of suspicion for infection and detailed local protocols established to guide empirical antimicrobial therapy. Although traditionally poor, the prognosis is slowly improving.
Implant restoration of the atrophic maxilla with concurrent mandibular rehabilitation
Authors: Gruber Elizabeth , James Graham
Published: April 2016

A case study is presented of a young patient with severe atrophy of the maxilla following aggressive periodontal disease and the subsequent management. This is illustrated with radiographic images. Methods of classification of bone quality and the remaining alveolar ridge form are presented. This is followed by a discussion of techniques for bone augmentation, the materials utilized and their various merits and preferred usages. Implant placement techniques, long-term prognosis and definitive restoration are considered.
High Reliability of a Scoring System for Implant Position in Undisplaced Femoral Neck Fractures
Authors: Viberg Bjarke , Bartholin Marie-Louise L. , Weber Kolja , Bech Rune D. , Palm Henrik , Schultz-Larsen Morten
Published: April 2016

Objectives:

The aim of this study was to evaluate the intrarater and interrater reliability of a scoring system for internal fixation (SIFA) in undisplaced femoral neck fractures (FNF).

Design:

A reproducibility study with a historical consecutive cohort.

Setting:

The patients were all treated at a level one trauma hospital.

Patients/Participants:

A cohort of patients with FNF, treated with 2 parallel implants, was retrieved using a local county register, and the cohort was assessed for undisplaced FNF until the desired sample size was reached. One hundred two patients had their x-ray images reviewed 2 times with a minimum 14 days interval, by 3 raters, all blinded for each other's results, and an independent person analyzed the data with unweighted kappa statistics.

Main Outcome Measurements:

Implant positions on the first postoperative anterior-posterior and axial radiographs were first visually assessed, then objectively measured according to SIFA, which consists of 5 individual measurements; screw tip distance, screw femoral shaft angle, inferior screw calcar distance, and screw position in the femoral head in the anterior-posterior and axial radiographs.

Results:

Visually assessed implant position gave intrarater kappa results for the individual components of SIFA at 0.40–0.75 (rater 1), 0.75–0.98 (rater 2), and 0.69–0.83 (rater 3), with interrater kappa results at 0.18–0.80 (combined range). Objectively measured implant position for the individual components of SIFA gave intrarater kappa results at 0.56–1.0 (rater 1), 0.74–0.89 (rater 2), and 0.81–0.94 (rater 3), with interrater kappa results at 0.56–0.85 (combined range). The overall SIFA score has similar higher intrarater and interrater results for the measured (0.51–0.78) compared with the visual assessment (0.13–0.78). The assessment in the axial view of the screw position in femoral head had the largest difference of acceptable positioning, when comparing visual assessment with the measured.

Conclusions:

The SIFA demonstrates substantial intrarater and interrater reliability (kappa 0.51–0.78), when raters make measurements of radiographs, but lower reliability (kappa 0.13–0.78) when raters visually assess the radiographs without measuring. The SIFA should be assessed on a large cohort, for correlation with clinical evaluation.