bluuebunny/crossref_metadata_2025 huggingface dataset:
Digital in Her DNA
Authors: Siriwat Rasintra , Grigg-Damberger Madeleine , Shah Vaishal
Published: August 2019

The most common sleep disorder in pre-adolescents and adolescents is insufficient sleep syndrome. The use of screen-based activities (e.g., cellphones, tablets, and video games) is a major contributor to insufficient and poor-quality sleep. The authors discuss changes in the sleep/wake pattern at the transition from pre-adolescent to adolescent age and various factors affecting these changes. They explain how self-imposed poor sleep hygiene practices and behaviors at bedtime affect sleep latency. Sleep logs or actigraphy can be useful tools in the confirmation of ISS. Strategies to avoid wake-promoting late evening activities and a consistent sleep/wake schedule are the keys to optimal daytime functioning. Treating insufficient sleep in adolescents with education and behavioral modification is effective in most cases.
Deep into that Darkness Peering . . . Stood There Wondering, Fearing
Authors: Rodriguez Carlos L. , Pillai Jagan A.
Published: August 2019

This chapter reviews the diagnosis and management of irregular sleep/wake rhythm disorder (ISWRD) and sundowning. ISWRD is characterized by lack of a clearly defined sleep/wake circadian rhythm with episodes of sleep and wake at varying times of the day or night, unrelated to a normal sleep/wake, day/night circadian rhythm Patients with neurodegenerative disorders are at increased risk for ISWRD. The diagnosis of ISWRD requires sleep log or actigraphy monitoring for at least 7 days. ISWRD is a common cause of institutionalization. Sundowning can further disrupt sleep and has been associated with more rapid progression of dementia. Mixed-modality treatment is used for the treatment of ISWRD and involves the integration of approaches to optimize entrainment to synchronizing factors and behavioral therapy.
Seizures, Stimulators, and Sleep, Oh My!
Authors: Somboon Thapanee , Foldvary-Schaefer Nancy
Published: August 2019

This chapter discusses the relationships between epilepsy and sleep disorders, and the impact of vagus nerve stimulation (VNS) on breathing in sleep. The prevalence of sleep disorders in people with epilepsy is twofold to threefold greater than estimates in the general population. Obstructive sleep apnea (OSA) is the most common sleep disorder investigated in epilepsy populations. Treatment of OSA has been shown to reduce seizures in some patients. In contrast, VNS therapy for epilepsy is associated with stimulation-induced respiratory changes in sleep, and in some cases it produces a clinical OSA syndrome. Given the high prevalence of sleep complaints among people with epilepsy, further research is warranted to confirm the role of sleep disorder therapies in epilepsy.
All Fall Down
Authors: Ashraf Fareeha , Yarahmadi Alireza , Zeft Andrew S. , Foldvary-Schaefer Nancy
Published: August 2019

Sleep disorder symptoms are rarely part of the clinical spectrum of paraneoplastic central nervous system disease. Ma1 and Ma2 antibodies involving mesencephalic and diencephalic structures, including the hypothalamus, can result in destruction of hypocretin neurons, leading to narcolepsy type 1 (formerly narcolepsy with cataplexy). This chapter presents a young man with testicular carcinoma and a devastating clinical syndrome of limbic encephalitis, supranuclear palsy, and narcolepsy with cataplexy in the setting of Ma1 and Ma2 paraneoplastic antibodies. Early treatment with removal of the underlying tumor and immunotherapy after several years resulted in a meaningful neurologic recovery. Paraneoplastic disorders should be considered in patients presenting with a subacute onset of narcolepsy in the setting of encephalitis and/or multifocal neurologic deficits.
A Painful Trifecta
Authors: Downey III Ralph , Mehra Reena , Davin Sara
Published: August 2019

In clinical practice, the treatment of sleep disturbance in the setting of chronic pain can be challenging. In the case presented, a patient with a longstanding history of insomnia, chronic pain, and psychiatric comorbidity was recently assessed and treated for mild obstructive sleep apnea. With treatment, there was substantial clinical improvement in several areas of functioning. This helps to illustrate that addressing coexisting sleep problems can help more refractory symptoms, such as chronic pain. While severe impairment persisted, this complex patient had a rapid change in symptoms. The dynamic interplay between sleep, pain, and psychiatric disorders is discussed, as well as the finding of alpha intrusions and alpha-delta sleep on the patient’s polysomnogram. Treatment implications are addressed.
Our Baby Can’t Eat, Can’t Breathe, and Can’t Sleep!
Authors: Blasberg Elizabeth A. , Kraai Tania L. , Grigg-Damberger Madeleine
Published: August 2019

An infant with severe congenital laryngomalacia presented with inspiratory stridor when feeding, crying, or supine, relieved by prone or upright repositioning. Suprasternal retractions, hypoxemia, feeding difficulties, and failure to thrive prompted admission to the pediatric intensive care unit. Symptoms of sleep disordered breathing contributed to the severity of her laryngomalacia. Overnight polysomnography confirmed severe obstructive sleep apnea and sleep-related hypoxemia. The patient underwent supraglottoplasty with resolution of the wake hypoxemia but with residual stridor and apnea. Revision supraglottoplasty led to remission of the stridor and obstructive sleep apnea but emergence of central sleep apnea. This case discusses the clinical features, diagnostic evaluation, and management of congenital laryngomalacia. Supraglottoplasty, reserved for infants with moderate or severe laryngomalacia, is the treatment of choice. Obstructive sleep apnea improves but usually does not fully remit after supraglottoplasty. Central sleep apnea is not uncommon in infants with laryngomalacia and may reflect immature or abnormal brainstem nuclei regulating regulation of respiration during sleep.
Spikes, Spikes Go Away!
Authors: Knight Elia M. Pestana , Grigg-Damberger Madeleine
Published: August 2019

The child described in this chapter presented with seizures and developmental regression and had continuous spike-wave discharges activated by non–rapid-eye-movement (NREM) sleep consistent with epileptic encephalopathy with continuous spikes and waves during slow-wave sleep (E-CSWS), which is a rare age-dependent pediatric epilepsy syndrome. The CSWS electroencephalographic pattern in children with E-CSWS usually develops 1 to 2 years after seizure onset. While the CSWS EEG pattern in NREM sleep is diagnostic of E-CSWS, the cardinal clinical symptoms are a progressive decline in cognitive, behavioral, and/or psychiatric functioning. The pattern of CSWS is more often associated with neurodevelopmental problems, and the almost continuous discharges are thought to contribute or cause them. Encountering a CSWS EEG on an EEG or PSG requires clinical correlation to determine whether it is (or will become) symptomatic, and whether it should (or can) be treated. CSWS affects all cognitive domains, including language and communication, temporo-spatial orientation, attention, and social interaction. Antecedent and birth history are usually normal, although structural brain abnormalities are seen in 20% to 50%, most often prenatal or perinatal lesions, involving thalamus in some.
Dying to Fall Asleep
Authors: Rundo Jessica Vensel , Mehta Hillor , Mehra Reena
Published: August 2019

Fatal familial insomnia (FFI) is a rare autosomal dominant genetic disease characterized by progressive insomnia, autonomic hyperactivity, memory deficits, hallucinations, and myoclonus. Unlike its name, insomnia is not the most common initial presentation in patients with FFI. More common features like autonomic hyperactivity (hypertension and tachycardia) are often missed, delaying the diagnosis of FFI. Genetic analysis of FFI shows a D178N-129M mutation that results in generation of insoluble proteins (prion proteins) that aggregate to form amyloid plaques, leading to deterioration of the central nervous system, particularly in the hypothalamus. This case illustrates the difficulty in determining a definitive diagnosis in patients with FFI. Unfortunately, no treatment or cure is available for FFI. The disease is fatal in all the patients.
Is the Jury Out or In?
Authors: May Anna M. , Gildea Thomas R. , Mehra Reena
Published: August 2019

This case illustrates potential perioperative complications associated with obstructive sleep apnea (OSA): respiratory decompensation sometimes leading to morbidity, mortality, increase in the level of care, and increased health care expenditures. OSA is common and affects more than 40% of the surgical population. However, an estimated 85% of those with OSA are undiagnosed preoperatively. This chapter describes an individual with severe OSA complicated by perioperative respiratory failure who required intensive care unit admission and emergent reintubation. This case is used to highlight perioperative considerations for OSA screening, testing, and treatment with a focus on respiratory management based on guideline recommendations. This case underscores the most common types and timing of such postoperative complications and ways to prevent and treat them.
He Sounds Like a Crow and Leaps from the Bed
Authors: Hoy Alexa , Foldvary-Schaefer Nancy , Grigg-Damberger Madeleine
Published: August 2019

Diagnosing multiple system atrophy (MSA) is a complex, interdisciplinary process due to the variation in symptom presentation. Diagnosing MSA requires following the case history; the early signs and symptoms are characteristic in many diseases while additional symptoms may seem unrelated or comorbid with other disorders. This case focuses on an individual diagnosed with Parkinson disease whose wife notices him gasping with a high-pitched sound during the night. A sleep study with audio/video recording determines this to be an inspiratory stridor, which confirms a diagnosis of MSA. Inspiratory stridor is due to either dystonia of the thyroarytenoid muscles or paralysis of the posterior cricoarytenoid muscles. Inspiratory stridor during sleep in an adult with parkinsonian symptoms warrants consideration of MSA, not Parkinson disease. Almost all patients with MSA have rapid-eye-movement (REM) sleep behavior disorder. A third of patients with MSA have inspiratory stridor, which typically occurs primarily in sleep. Inspiratory gasps awake and asleep are common in patients with MSA.
Did Cancer Kill My Sleep?
Authors: Ashton Kathleen , Thompson Cheryl L.
Published: August 2019

A two-time breast cancer survivor is troubled by worry of her cancer returning; along with poor sleep hygiene and lack of routine schedule, this leads to insomnia. After a negative polysomnogram, she is evaluated by a psychologist trained in sleep and integrated into the breast cancer clinic. Cognitive-behavioral therapy for insomnia is recommended. Insomnia is common among breast cancer patients and survivors and is likely due to a combination of factors, including anxiety over prognosis and treatment side effects, which are sometimes long-lasting. Treatment of insomnia in these patients has been shown to improve their quality of life. Short sleep duration and circadian rhythm disturbances are associated with cancer development, progression, and prognosis.
Bilevel PAP Transforms a Teen’s Life
Authors: Royce Frederick H. , Shah Vaishal
Published: August 2019

This chapter examines the interplay between obesity and the selection of treatment for severe sleep obstructed breathing in children and adolescents. It reviews the physiology of obstructive sleep apnea and hypoventilation, as well as the importance of partial-pressure carbon dioxide monitoring in evaluating sleep disordered breathing in obese children. It discusses the effectiveness, adherence, and clinical outcomes of various treatment options for pediatric obstructive sleep apnea/hypoventilation, including adenotonsillectomy, positive airway pressure (PAP) therapy, and weight loss. It also reviews current literature on newer-generation, autotitrating PAP devices and their role in pediatric obstructive sleep apnea. Finally, it discusses the role of oxygen therapy in the management of pediatric obstructive sleep apnea.
She Works Hard for Her Sleep
Authors: Vanek Robon , Kempke Nancy
Published: August 2019

Shift work and long work hours, such as 12-hour shifts, can disturb sleep and circadian rhythms. Shift work disorder is a circadian rhythm disorder in which excessive sleepiness and/or insomnia due to work schedule occur. There is a circadian misalignment between the timing of the sleep/wake schedule and the circadian pressures for sleep and wakefulness. Between 10% and 38% of nightshift and rotating shift workers experience shift work disorder. There can be interruptions during sleep caused by light, noise, and social obligations when sleep occurs at unusual times, resulting in a short sleep duration/inadequate sleep and poor sleep quality. Sleep logs provide valuable information. To improve the quantity and quality of sleep, the sleep environment and timing of light exposure need to be optimized, and limiting interruptions during sleep is recommended. Wake-promoting agents such as armodafinil prior to work may be needed for fatigue management. Validated tools can aid in diagnosis, and there may be an underutilization of sleep specialists in these patients.
Pulmonary Arterial Hypertension
Authors: Mar Hugo Paz y , Chaisson Neal F.
Published: August 2019

The high prevalence of pulmonary arterial hypertension (PAH) in patients with obstructive sleep apnea (OSA) and the putative pathophysiologic connections have been extensively documented. Conversely, patients with established PAH are at risk for sleep-related ventilatory instability, including OSA, central sleep apnea, and nocturnal desaturations. This chapter reviews the prevalence and pathophysiologic interactions of these conditions, the interplay with associated disorders, and the effects of continuous positive airway pressure therapy on pulmonary hemodynamics. In patients with OSA, chronic effects of repetitive hypoxia as well as comorbidities, including chronic obstructive pulmonary disease and left-sided heart dysfunction, play a role in promoting pulmonary hypertension. Sleep disordered breathing, representing a spectrum of sleep-related breathing disorders inclusive of OSA, is highly prevalent among patients with established pulmonary hypertension. Obstructive events, central sleep apnea, and nocturnal hypoxia are within the spectrum of sleep-related breathing disorders in pulmonary hypertension. The mechanisms for these associations remain speculative.
Moving Forward When CPAP Fails
Authors: Coy Todd , Mehra Reena , Bae Charles
Published: August 2019

This chapter discusses the role of oral appliance (OA) therapy for treating obstructive sleep apnea (OSA). Positive airway pressure (PAP) therapy is often the first-line treatment for OSA, but the average PAP adherence is approximately 50%. OA is a good alternative to PAP therapy that can be combined with other conservative options, such as weight loss and positional therapy. Many patients with OSA who cannot tolerate PAP therapy may be able to be managed by OA. Short-term side effects of OA device usage for OSA include tooth pain, gum soreness/gingival irritation, muscle soreness, myofascial pain, excessive salivation, dryness, and abnormal occlusion. OA adherence for OSA treatment is greater than that observed for PAP and shows comparable improvement in subjective sleepiness. PAP therapy continues to show greater improvement in the apnea/hypopnea and hypoxia index.
Respiratory Physiology in Critical Illness
Authors: Kwon Minkyung , Diaz-Gomez Jose L.
Published: August 2019

The practice of critical care medicine requires detailed knowledge of the practical aspects of respiratory physiology, including lung mechanics, the physiology of hypoxia, and the control of breathing. Before the lungs can enable gas exchange, air must move from the upper airway down a series of branching small airways and reach the alveoli. In the walls of the alveoli, capillaries form a dense network and receive blood flowing from the pulmonary artery before it flows to the pulmonary vein. Between the capillary network and the alveoli lies a thin blood-gas barrier through which oxygen and carbon dioxide move, chiefly by simple diffusion.
Mechanical Ventilation: Basic Modes
Authors: Lowell Amelia A.
Published: August 2019

The main goal of mechanical ventilation is to unload the respiratory muscles to facilitate oxygenation and ventilation. This is accomplished by providing a minute ventilation (VE) (respiratory rate × tidal volume [VT]) that will result in adequate alveolar ventilation coupled with supplemental oxygen and a mean airway pressure that will result in adequate arterial oxygenation.
Nutrition in Critical Illness
Authors: Vizzini Angela N. , Hamdan Mireille H.
Published: August 2019

Nutritional care of critically ill patients prompts considerations unique to this patient population. For many years it has been postulated that the inflammation and stress response that accompany critical illness contribute to hypermetabolism and increased nutrient requirements. There is a reasonable consensus that nutrition therapy tailored to the patient’s energy and protein requirements aids in recovery, maintains lean muscle mass, and decreases infectious complications. This chapter addresses nutritional issues in critically ill patients and suggests appropriate interventions and monitoring to prevent complications and facilitate recovery from critical illness.
Neurologic Examination in Neurocritical Illness
Authors: Wijdicks Eelco F. M.
Published: August 2019

Neurologic examination of critically ill neurologic patients must be the uncompromised gold standard in any evaluation. Without it or when confounded, the attending physician is prone to make errors in diagnosis, treatment, and prognosis. The localization of a disease process in a specific part of the brain (eg, the cerebrum, midbrain, pons, or medulla oblongata), spinal cord, neural plexuses, or peripheral nerves constitutes the essence of a neurologic evaluation, but neurologists resort to several neuroimaging modalities when localization is uncertain.
Intracranial Pressure
Authors: Wijdicks Eelco F. M. , Freeman William D.
Published: August 2019

Cerebrospinal fluid (CSF) fills the subarachnoid space, spinal canal, and ventricles of the brain. CSF is enclosed within the brain by the pial layer, ependymal cells lining the ventricles, and the epithelial surface of the choroid plexus, where it is largely produced. Choroid plexus is present throughout the ventricular system with the exception of the frontal and occipital horns of the lateral ventricle and the cerebral aqueduct. The vascular smooth muscle and the epithelium of the choroid plexus receive both sympathetic and parasympathetic input. In an adult, CSF is normally acellular. A normal spinal sample may contain up to 5 white blood cells (WBCs) or red blood cells (RBCs). CSF allows for a route of delivery and removal of nutrients, hormones, and transmitters for the brain.
Cerebrospinal Physiology
Authors: Zachariah Joseph
Published: August 2019

With its high metabolic rate and lack of substrate stores, the brain is dependent on a constant supply of oxygen and glucose. If blood flow stops, alterations in brain function occur within seconds and irreversible injury can occur within a few minutes. Many patients admitted to neurosciences intensive care units have acute strokes, are eligible for endovascular procedures, and may need other measures to preserve adequate cerebral blood flow. An understanding of the blood supply, venous drainage, and factors affecting cerebral perfusion is thus pivotal to the practice of neurologic critical care. This chapter reviews the anatomical and physiologic principles governing cerebral circulation and blood flow.
Cerebral Circulation and Cerebral Blood Flow
Authors: Abcejo Arnoley S. , Pasternak Jeffrey J.
Published: August 2019

Cardiac arrest occurs suddenly, often without premonitory symptoms. Consciousness is lost within seconds to minutes because of insufficient cerebral blood flow in the midst of complete hemodynamic collapse. Anoxic-ischemic brain injury is most commonly caused by cardiac arrest, which is frequently lethal; of the US patients with out-of-hospital cardiac arrest treated by emergency medical services, almost 90% die. Among the patients who survive to hospital admission, inpatient mortality may be decreasing, but a substantial number of those survivors have poor neurologic outcomes from anoxic-ischemic brain injury.
Consequences of Anoxia and Ischemia to the Brain
Authors: Fugate Jennifer E.
Published: August 2019

Systemic illness can have an abrupt and sometimes profound effect on the central nervous system. Organ failure and acute electrolyte disturbances may cause neurologic manifestations that are often accompanied by a decline in consciousness. Secondary injury is characterized by demyelination, cerebral edema, and anoxic-ischemic brain injury.
Neurogenic Cardiac Manifestations
Authors: Braksick Sherri A. , Wijdicks Eelco F. M.
Published: August 2019

Paroxysmal sympathetic hyperactivity (PSH) is a form of acute dysautonomia that can occur after several types of acute (usually severe) structural brain injury. PSH typically occurs after traumatic brain injury (TBI) with diffuse axonal injury, yet it can also occur after aneurysmal subarachnoid hemorrhage, encephalitis, massive fat or air embolism, or profound anoxic-ischemic brain injury, often with each condition leading to prolonged unconsciousness. The development of PSH is associated with longer hospital stays, and it may be associated with increased mortality and worse outcomes.
Paroxysmal Sympathetic Hyperactivity
Authors: Gobeske Kevin T.
Published: August 2019

Neurologic examination of critically ill neurologic patients must be the uncompromised gold standard in any evaluation. Without it or when confounded, the attending physician is prone to make errors in diagnosis and prognosis. Even in intensive care units (ICUs), where abnormal laboratory test results and imaging findings are common, knowledge of the neurology of neurocritical care includes understanding the clinical course after initial presentation. Despite surprises delivered by magnetic resonance imaging, the clinical practice of lesion localization must be a component of the practice of neurocritical care and be based on a full knowledge of neurologic tests, an approach typically lacking in clinical trial–devised scales or scores.
Pulmonary Embolism: An Overview
Authors: Nokes Brandon T. , Cartin-Ceba Rodrigo
Published: August 2019

Venous thromboembolism (VTE) is a major public health concern with an annual incidence of 1 per 1,000 patients in the United States. VTE encompasses a spectrum of diseases including deep vein thrombosis (DVT) and pulmonary embolism (PE). DVT is a precursor to PE, and approximately 80% of patients have DVT when PE is diagnosed. The risk factors for PE are the same as those for DVT; consequently, diagnosis and management of VTE are contingent on the underlying risk factors and the extent of disease. A suspected VTE diagnosis should be pursued with risk stratification tools such as the Wells DVT and PE criteria and the Revised Geneva Score for PE. This chapter reviews PE diagnosis, risk stratification, and management.
Asthma in the Critically Ill Patient
Authors: Danaraj Jonathan J. , Lee Augustine S.
Published: August 2019

Asthma is a common condition that affects an estimated 24 million children and adults in the United States (prevalence, 8%-10%). Globally, over 300 million people are affected and the number is expected to increase. The age distribution is bimodal, but in most patients, asthma is diagnosed before age 18 years (male to female ratio, 2:1 in children; 1:1 in adults). Susceptibility to asthma is multifactorial with both genetic and environmental factors. The strongest risk factor is atopy, a sensitivity to the development of immunoglobulin E (IgE) to specific allergens. A person with atopy is 3- to 4-fold more likely to have asthma than a person without atopy. Other risk factors include birth weight, prematurity, tobacco use (including secondary exposure), and obesity.
Chronic Obstructive Pulmonary Disease Exacerbation
Authors: Mira-Avendano Isabel , Kwon Minkyung
Published: August 2019

Patients with chronic obstructive pulmonary disease (COPD) have recurring or continuous obstruction of bronchial airflow. The disease is usually characterized by progressive chronic airway inflammation that results from smooth muscle hypertrophy, airway ciliary dysfunction, and excessive mucous production, which ultimately increases airway resistance and hyperactivity. Parenchymal destruction associated with emphysema increases lung compliance, which further decreases expiratory airflow. COPD exacerbation can be precipitated by several factors, but the most common causes are respiratory tract infections (viral or bacterial).
Pleural Diseases in Critical Care Medicine
Authors: Linga Karthika R. , Patel Neal M.
Published: August 2019

Pleural disease often affects critically ill patients and is usually related to trauma (including accidental perforation) or infection. Pneumothorax, a potentially life-threatening condition, requires early clinical recognition and sometimes urgent treatment. General intensivists often encounter pneumothorax after a procedure such as catheter placement. Neurointensivists often encounter pneumothorax after polytrauma or recent tunneling of a ventriculoperitoneal catheter.
Pulmonary Hypertension and Right-Sided Heart Failure in the Critically Ill
Authors: Burger Charles D.
Published: August 2019

Pulmonary hypertension (PH) was defined hemodynamically at the Fifth World Symposium on Pulmonary Hypertension (WSPH) as a mean pulmonary artery (PA) pressure (mPAP) of 25 mm Hg or more. Five diagnostic groups represent the various causes of PH. Group 1 pulmonary arterial hypertension (PAH) requires both an elevated mPAP and a pulmonary vascular resistance (PVR) of at least 3 Wood units; therefore, the left-sided heart filling pressures are not elevated (pulmonary arterial wedge pressure [PAWP] ≤15 mm Hg). Conversely, in group 2 PH, left-sided heart disease causes an elevation in PAWP. Group 3 PH is due to chronic hypoxemia typically from lung disease, group 4 PH is chronic thromboembolic PH, and group 5 PH is a miscellaneous category.
Cardiac Rhythm and Conduction Disturbances
Authors: Gonzalez Yahaira Ortiz , Kusumoto Fred
Published: August 2019

Patients in the intensive care unit (ICU) are exposed to several physiologic stressors that may trigger cardiac arrhythmias and lead to hemodynamic instability. Prompt recognition and initiation of appropriate therapies for arrhythmias is important because critically ill patients with arrhythmias (compared to patients without arrhythmias) have longer hospitalizations and higher mortality (30.8% vs 21.2%). Arrhythmias are classified as tachyarrhythmias or bradyarrhythmias. The most common sustained arrhythmias are supraventricular; atrial fibrillation is the most prevalent. Among the ventricular arrhythmias, up to 50% are monomorphic ventricular tachycardias.
Hypertensive Emergencies
Authors: Hill Denzil R. , Onigkeit James A.
Published: August 2019

Hypertension is a global problem. According to the World Heart Federation, nearly 1 billion people worldwide have hypertension, and nearly two-thirds of them live in developing countries. By the year 2025, hypertension may affect more than 1.5 billion people. Uncontrolled hypertension is 1 of the main causes of premature death worldwide and the most common risk factor for heart disease, stroke, and renal diseases.
Cardiopulmonary Resuscitation
Authors: Patch Richard K.
Published: August 2019

Cardiac arrest is a complex dynamic process that may occur as an end point of multiple disease states. The field of cardiopulmonary resuscitation (CPR) for cardiac arrest continues to evolve, and guidelines are updated in accordance with evidence-based evaluation of current medical literature. The guidelines are the cornerstone for the management of cardiac arrest in out-of-hospital, in-hospital, and intraoperative settings. Furthermore, the implementation of comprehensive postarrest care is vital for improving patient outcomes.
Diabetes Insipidus
Authors: Erickson Dana
Published: August 2019

Diabetes insipidus (DI) results from the impaired secretion or action of antidiuretic hormone (ADH). Central DI occurs with partial or complete ADH deficiency; nephrogenic DI occurs with impaired action of ADH in the kidneys. These defects result in the production of large volumes of inappropriately dilute urine, which increases plasma osmolality and eventually stimulates thirst.
Glycemic Control in Neurocritically Ill Patients
Authors: Venegas-Borsellino Carla P. , Pizzi Michael A. , Naranjo-Sierra Santiago
Published: August 2019

Hyperglycemia, hypoglycemia, and variable blood glucose levels are associated with poor outcomes in critically ill patients. Patients with acute brain injury are sensitive to changes in glycemic levels because brain metabolism depends on a continuous, reliable supply of glucose. Numerous studies have shown that even moderate hypoglycemia may cause pronounced neuroglycopenia. Conversely hyperglycemia, which is prevalent in neurocritically ill patients, has been related to adverse outcomes after traumatic brain injury, ischemic stroke, intracranial hemorrhage, and subarachnoid hemorrhage.
Acute Gastrointestinal Hemorrhage
Authors: Franco Pablo Moreno , Lowman Philip E.
Published: August 2019

Gastrointestinal hemorrhage (GIH) is a common medical problem that is associated with considerable morbidity, mortality, and medical costs. The initial approach when GIH is suspected depends on a patient’s clinical stability, which will vary depending on the amount and speed of blood loss. Therefore, if time allows, the initial evaluation should include history, physical examination, laboratory tests, and, possibly, nasogastric tube placement.
Paralytic and Obstructive Ileus
Authors: Canabal Juan M.
Published: August 2019

Ileus is the most common manifestation of acute gastrointestinal injury which exhibits grades of severity in the critically ill. Appropriate characterization of ileus as adynamic or mechanical in origin determines its management. This chapter discusses the most important causes, clinical and radiologic findings, and appropriate management of ileus that develops in patients in the intensive care unit.
Acute Vascular Disorders of the Intestine
Authors: Mousa Omar Y. , Pungpapong Surakit
Published: August 2019

Mesenteric ischemia is caused by insufficient blood supply to the foregut and intestines. When the blood supply does not meet the metabolic requirements of these organs, catastrophic complications may result. Death is imminent in the setting of acute mesenteric ischemia if diagnosis is delayed; associated mortality rates are as high as 60% to 80%. The severity and extent of this disease depend on the nature of the vascular obstruction and the type of occluded vessel.
Abdominal Compartment Syndrome
Authors: Johnson Daniel J.
Published: August 2019

In abdominal compartment syndrome (ACS), a fixed compartment (the abdomen with defined myofascial elements) is subjected to increased pressure. The result is decreased organ perfusion and subsequent dysfunction inside the abdominal cavity and the respiratory and cardiovascular systems. Given the affect of treatment for organ dysfunction, an accurate characterization of primary illness progression and ACS is crucial for diagnostic assessment.
Acute Kidney Injury
Authors: Sakhuja Ankit , Kashani Kianoush B.
Published: August 2019

Acute kidney injury (AKI) is a complex disorder that encompasses a broad spectrum of clinical presentations ranging from subclinical injury to complete loss of kidney function. AKI is fairly common in critically ill patients. Among patients who have similar conditions, those who have development of AKI have worse outcomes than those who do not. There have been significant strides in understanding the pathophysiology of AKI in recent years, but management is mostly supportive, and prevention remains critical for improving outcomes.
Anemia and Blood Transfusion
Authors: Hughes Joy D. , Rivera Mariela , Park Myung S.
Published: August 2019

Critically ill patients commonly present with anemia, defined as a hemoglobin level less than 13.0 g/dL in men and less than 11.6 g/dL in women or as clinical signs of bleeding, including tachycardia and low urine output with active hemorrhage. Anemia is common, occurring in up to a third of critically ill patients, and is associated with high morbidity and mortality rates, particularly in patients with central nervous system injuries and disease. The causes of anemia can vary from chronic conditions such as kidney disease or malnutrition to acute conditions such as bleeding or consumptive coagulopathy.
Hematologic and Oncologic Complications in the Intensive Care Unit
Authors: Ruthman Carl A. , Yataco Jose C.
Published: August 2019

Patients with cancer can present to the ICU with the complications and conditions of the general population, but a few are particular to their type of cancer or treatment. Some of the most common of cancer-related ICU complications are reviewed in this chapter, particularly those that need complex and urgent management.
Thrombocytopenia and Thrombocytopathy
Authors: Johns Gretchen
Published: August 2019

Platelet disorders are quantitative or qualitative, or both. Either markedly increased or decreased numbers of platelets can cause harmful sequelae. Platelet disorders can be divided into acquired or hereditary; acquired disorders are much more common than congenital disorders. Platelet disorders can be due to increased platelet destruction or decreased platelet production. Pseudothrombocytopenia, dilutional effects, or possible splenic sequestration should be considered when the platelet count is low for the first time. The recent addition of a drug, commonly used in intensive care units, is also an important consideration for patients with newly acquired thrombocytopenia.
Diagnosis and Management of Acquired Bleeding Disorders
Authors: Pruthi Rajiv K.
Published: August 2019

The hemostatic response to vascular injury consists of vascular constriction, platelet activation resulting in platelet adhesion (mediated by von Willebrand factor), and platelet aggregation resulting in an initial platelet plug formation at the site of vascular injury. This platelet plug is stabilized by formation of fibrin, which results from activation of the procoagulant coagulation factors. Congenital or acquired abnormalities of the procoagulant factors result in a bleeding and thrombotic tendency of variable severity. Acquired abnormalities of the procoagulant system are typically associated underlying systemic disorders; however, they may also be idiopathic. Recognition, laboratory diagnosis, and principles of management of acquired coagulopathy are reviewed in this chapter.
Anticoagulation Monitoring and Reversal
Authors: Kinard Theresa N.
Published: August 2019

The balance of natural procoagulant and anticoagulant activity within the body is delicate, and a minor disruption may lead to bleeding or clotting complications. Anticoagulation in critical illness is often necessary for a host of reasons, either prophylactic or therapeutic. This chapter reviews common anticoagulation management issues in the critically ill patient, such as optimal laboratory monitoring of anticoagulation therapy and urgent reversal options, focusing on the most common anticoagulants used in current practice.
Therapeutic Plasma Exchange for Acute Hematologic Disorders
Authors: Adamski Jill
Published: August 2019

Therapeutic plasma exchange (TPE) is a process by which whole blood is removed from a patient and separated into 3 components: red blood cells, white blood cells (buffy coat), and plasma. After separation, the plasma is discarded, and the other blood components are returned to the patient along with exogenous fluid to replace the removed plasma. TPE is an important tool to remove pathogenic substances (eg, antibodies) from plasma, and this technique is considered first-line therapy for numerous conditions that affect patients in the critical care unit. This chapter describes the role of TPE in management of hematologic disorders, some of which have neurologic manifestations.
Infectious Diseases Complicating Critical Care
Authors: Aviles David A. Sotello , Hellinger Walter C.
Published: August 2019

Infection is a common complication in the intensive care unit (ICU). Furthermore, infection more than doubles the mortality rate in the ICU. Antibiotic resistance in Staphylococcus aureus, Enterococcus, Enterobacteriaceae, and fungal infection is among the most challenging issues in the ICU. In addition, critical illness affects antibiotic pharmacokinetics. Thus, implementation of strategies to prevent infection is of utmost importance to improve patient outcome.
Initial Approach to the Management of Multisystem Trauma
Authors: Morris David S.
Published: August 2019

Nearly 200,000 people die of injury-related causes in the United States each year, and injury is the leading cause of death for all patients aged 1 to 44 years. Approximately 30 million people sustain nonfatal injuries each year, which results in about 29 million emergency department visits and 3 million hospital admissions. Management of severely injured patients, typically defined as having an Injury Severity Score greater than 15 is best managed in a level I or level II trauma center. Any physician who provides care for critically ill patients should have a basic familiarity with the fundamentals of trauma care.
Chest and Abdominal Trauma
Authors: Hughes Joy D. , Morris David S.
Published: August 2019

Injuries to the chest or abdomen frequently affect management of traumatic brain injury (TBI). Neurocritical care clinicians must be familiar with management principles for these injuries. This chapter reviews common injuries to the torso, with particular attention to problems affecting neurologic management, but it cannot provide an exhaustive list of injuries and management principles for this broad topic. Close interaction with clinicians familiar with the management of nonneurologic traumatic injury is recommended.
Skeletal Trauma
Authors: Bingham Joshua S. , Renfree Kevin J.
Published: August 2019

In critically ill patients with polytrauma, a surge in the inflammatory response can lead to further injury and multisystem organ failure if not treated appropriately. During this acute inflammatory period, only life-threatening injuries should be treated. This chapter discusses the appropriate workup and management of skeletal trauma in critically ill patients.
Burns and Electrical Injuries
Authors: Nokes Brandon T. , Sen Ayan
Published: August 2019

Burn injuries may cause morbidity and death, and patients may have widely variable presentations and outcomes. This chapter focuses on the critical care aspects of burn injury and management issues of burn and electrical injuries. Burns are classified according to the amount of total body surface area (TBSA) affected, the depth of burn, and the type of exposure associated with the burn. More specifically, burns can be chemical, electrical, or thermal. Burn severity is determined by the depth of involvement.
Cardiothoracic Surgery and Postoperative Intensive Care
Authors: Sanz Juan G. Ripoll , Ratzlaff Robert A.
Published: August 2019

Cardiothoracic surgical (CTS) critical care responsibilities have progressively shifted away from surgeons and toward intensivists in the past several decades. CTS patients present unique challenges, and optimal patient care in the intensive care unit is a main factor for the prevention of deaths after any type of open heart surgery.
Mechanical Circulatory Assist Devices
Authors: Sen Ayan , Patel Bhavesh M.
Published: August 2019

Mechanical circulatory assist devices (MCADs) are used in patients with decompensated heart failure refractory to medical therapy. The devices are used as a bridge to transplant, as a bridge to recovery for reversible conditions, as a bridge to decision while a patient’s eligibility for transplant is determined, and as destination therapy to support left-sided heart function when a patient is not eligible for transplant. MCADs restore tissue circulation by increasing blood flow and, thereby, improving organ function.
Critical Care of Heart-Lung and Lung Transplant Recipients
Authors: Sista Ramachandra R.
Published: August 2019

Lung transplant is a complex procedure that has been a successful therapy for various end-stage lung diseases since the 1980s. Combined heart-lung transplant, however, is performed much less frequently than in the past. Survival rates after lung transplant have been stable over the past several years (90% survival at 3 months, 80% at 1 year, 60% at 3 years, and 45% at 5 years). The types of transplant procedures available and the general indications for lung transplant are listed in this chapter.
Clinical Management of Liver Transplant Recipients
Authors: Gali Bhargavi
Published: August 2019

Improvements in surgical, anesthetic, and critical care management since the 1990s have led to better outcomes for liver transplant (LT) recipients. Estimated 1-year survival after LT increased from 64% in 1989 to 89% in 2014. Of all transplants performed in the United States, 23% are LTs, and more than 7,000 LTs were performed in 2015. In most medical centers, LT recipients are initially cared for in an intensive care unit (ICU). With changes in the intraoperative surgical and anesthetic management, the typical time and resources required for immediate postoperative care have decreased, allowing for rapid recovery protocols to be instituted in some centers for patients without clinical complications.
Neuroleptic Malignant Syndrome and Hyperthermia
Authors: Renew J. Ross , Mordecai Monica
Published: August 2019

Neuroleptic malignant syndrome (NMS) is an uncommon, potentially fatal reaction to antipsychotic medications. Most cases occur in men between the ages of 20 and 50 because they have the highest proportion of antipsychotic consumption. The prevalence of NMS has been reported as 0.07% to 2.2%, but the published diagnostic criteria for NMS varied widely until the Diagnostic and Statistical Manual of Mental Disorders addressed the issue in 2013. NMS is characterized by a constellation of clinical symptoms and laboratory abnormalities, including hyperthermia, muscle rigidity, and increased serum creatine kinase levels. Patients may also present with tremor, altered mental status, autonomic dysfunction, and leukocytosis.
Clinical Toxicology: Selected Drugs of Abuse and Chemical and Biological Warfare Agents
Authors: Sztajnkrycer Matthew D.
Published: August 2019

Approximately 10% of the US population 12 years or older uses illicit drugs. Although illicit drug use is typically considered a disease of the young, substance misuse is also a serious risk for older persons. Chemical and biological agents have been used in warfare for millennia. Chemical weapons are regulated under the 1993 Chemical Weapons Convention. Classic chemical weapons include nerve agents, vesicants, blood agents (cellular asphyxiants [eg, cyanide]), choking agents (pulmonary toxicity [eg, phosgene and chlorine]), and incapacitating agents (nonlethal [eg, 3-quinuclidinyl benzilate]). The Centers for Disease Control and Prevention (CDC) classifies biological warfare agents into Category A, B, or C. Category A agents are of greatest concern.
Diagnosis and Management of Hemispheric Infarction
Authors: Grewal Sanjeet S. , Brown Benjamin L.
Published: August 2019

Hemispheric infarction is a major cause of morbidity and death among patients with acute stroke. These patients must receive a timely diagnosis and treatment for the best outcomes. Treatment is often multimodal and requires close and meaningful communication with the patient and family about management options and the risks and benefits of each.
Adult Primary Central Nervous System Vasculitis
Authors: Salvarani Carlo , Brown Robert D. , Hunder Gene G.
Published: August 2019

Primary central nervous system vasculitis (PCNSV) is an infrequent and not well understood form of vasculitis that is limited to the brain and spinal cord. However, PCNSV is the most frequent vasculitis involving the central nervous system. Men and women are similarly affected, and the median age at diagnosis is approximately 50 years.
Cerebral Venous and Dural Sinus Thrombosis
Authors: Hocker Sara E.
Published: August 2019

Cerebral venous and dural sinus thrombosis (CVDST) is a rare cause of stroke that accounts for only 0.5% to 1% of all strokes. Diagnosis is challenging because of the diverse spectrum of clinical presentations. Onset is usually acute or subacute, but symptoms may be subtle, and neurologic examination findings may be normal. When a stroke occurs, it is often a hemorrhagic infarct. Therefore, to make a timely diagnosis, a high degree of awareness is required when at-risk patients present with neurologic symptoms or signs.
Cervical Arterial Dissection
Authors: Demaerschalk Bart M.
Published: August 2019

Cervical arterial dissections (CDs) are among the most common causes of stroke in young and middle-aged adults. CD is most prevalent in the upper cervical spine and may involve either the vertebral arteries or the carotid arteries. Mechanical forces can lead to intimal injuries of the cervical arteries and result in CD.
Unstable Spinal Fractures
Authors: Clifton William E. , Pichelmann Mark A.
Published: August 2019

Traumatic spinal injuries occur relatively frequently, with an annual incidence of about 12,000 patients per year in the United States. Modern advances in critical care management of patients with spinal injuries and spinal cord injuries have greatly decreased mortality. Therefore, the prevalence in the United States is more than 200,000 patients per year. The importance of early diagnosis and proper management of acute spinal fractures cannot be understated. This chapter reviews the different types of bony and ligamentous disruption in the cervical, thoracic, lumbar, and sacral spine that can lead to new or worsened neurologic injury if left untreated.
Acute Bacterial Meningitis
Authors: Wijdicks Eelco F. M.
Published: August 2019

Meningitis, an infection of the meninges and subarachnoid space, is a syndrome involving the cortex and vasculature that leads to vasculitis and secondary infarctions. The cerebral venous system is involved in severe cases. Acute bacterial meningitis usually results from community-acquired infections, but when it occurs in hospitalized patients (ie, nosocomial bacterial meningitis), it is usually due to invasive procedures. Factors that increase the risk of community-acquired meningitis include the immunocompromised state, human immunodeficiency virus infections, asplenia, and genetic factors such as complement factor deficiencies. In most adults with acute bacterial meningitis, a normal state of health is first interrupted by an upper respiratory tract infection or an ear infection that does not improve with antibiotic therapy. The potential source for acute bacterial meningitis, such as pneumonia, paranasal sinusitis, or middle ear infection, should be sought.
Brain Abscess and Spinal Epidural Abscess
Authors: Chen Selby G.
Published: August 2019

Two infections of the brain are relatively common. Patients with brain abscess are often critically ill and have a high mortality rate. The reported incidence of brain abscesses ranges from 0.4 to 0.9 per 100,000 people. In contrast, spinal epidural abscess (SEA), an infection of the epidural space, has increased in incidence from approximately 0.2 to 1.2 per 10,000 hospital admissions in the mid-1970s to a currently estimated 2.0 to 12.5 per 10,000 admissions. Both disorders are now more easily detected with magnetic resonance imaging (MRI), and this has improved early management, but clinical recognition is still a challenge for many physicians.