bluuebunny/crossref_metadata_2025 huggingface dataset:
Management of septic shock in the critically ill
Authors: Peake Sandra L. , Maiden Matthew J.
Published: April 2016

The management of septic shock is a medical emergency. Following prompt recognition, treatment priorities are haemodynamic resuscitation, empirical antimicrobials, urgent control of the source of infection and monitoring the response to therapy. Haemodynamic resuscitation is focused on maintaining an adequate macrocirculation, while also ensuring adequacy of microcirculatory blood flow to the cells. Intravenous fluids and catecholamines have been the mainstay of therapy. However, the amount and type of fluids, choice of vasoactive medications, and the appropriate resuscitation endpoints have been questioned. Greater awareness of the importance of resuscitating the microcirculation and cell function have led to endpoints such as venous O2 saturation and changes in lactate levels becoming resuscitation targets. Urgent definitive treatment of the infection is also crucial. This requires prompt broad-spectrum empirical antimicrobial therapy, draining infected collections and removing infected medical devices. Despite extensive research, no new therapies have improved survival from septic shock.
Renal injury biomarkers in the critically ill
Authors: Prowle John R.
Published: April 2016

Acute kidney injury (AKI) is a common complication of critical illness and its occurrence has been independently associated with both short- and longer-term morbidity and mortality. However, conventional diagnosis of AKI, based on rises in serum creatinine, can be delayed and inaccurate, particularly in the context of critical illness. These diagnostic limitations potentially prevent timely intervention and appropriate follow-up of patients experiencing AKI. Recently, a number of novel urinary and serum biomarkers of AKI have been described that may provide earlier and more precise diagnosis. Importantly, a number of these substances are biologically-linked to the pathophysiology of acute tubular injury. However, true validation and widespread clinical uptake of these biomarkers is likely to require demonstration of improved patients’ outcomes as a consequence of biomarker-driven clinical interventions.
The host response to infection in the critically ill
Authors: Wiersinga W. Joost , van der Poll Tom
Published: April 2016

Infection continues to be a leading cause of intensive care unit death. The host response to infection can be seen as a pattern recognition receptor (PRR)-mediated dysregulation of the immune system following pathogen invasion in which a careful balance between inflammatory and anti-inflammatory responses is vital. A measured and rapid response to microbial invasion is essential to health. The same immunological and coagulation systems that protect against localized infection can act to our disadvantage when these systems are activated systemically during generalized microbial infection. Toll-like receptors (TLR), the inflammasomes and other PRRs initiate the host response after recognition of pathogen-associated-molecular-patterns (PAMPs) or endogenous danger-associated-molecular-patterns (DAMPs). The systemic host response to infection will result in activation of coagulation, downregulation of physiological anticoagulant mechanisms, and inhibition of fibrinolysis. Further dissection of the role of host–pathogen interactions, the cytokine response, the coagulation cascade and their multidirectional interactions in sepsis should lead towards the development of new therapeutic approaches in the critically ill who are faced with infection.
Ischaemia-reperfusion injury in the critically ill
Authors: Fink Mitchell P.
Published: April 2016

Ischaemia/reperfusion (I/R) injury contributes to the pathogenesis of many common clinical conditions, including stroke, myocardial damage after percutaneous intervention for acute coronary artery occlusion, primary graft dysfunction after solid organ transplantation. The mechanisms that are responsible for I/R injury remain incompletely understood, but damage caused by reactive oxygen species (ROS) and reactive nitrogen species clearly is important. A number of therapeutic approaches, such as administration of ROS scavengers, are effective in animal models of I/R injury, but for the most part, translation of these findings into strategies that can clearly benefit patients has yet to be achieved.
Repair and recovery mechanisms following critical illness
Authors: Bellingan Geoffrey , Patel Brijesh V.
Published: April 2016

Inflammation is the beneficial host response to foreign challenge or tissue injury that ultimately leads to the restoration of tissue structure and function. Critical illness is associated with an overwhelming and prolonged inflammatory activation. Resolution of the inflammatory response is an active process that requires removal of the inciting stimuli, cessation of the pro-inflammatory response, a timely coordinated removal of tissue leukocyte infiltration, a conversion from ‘toxic’ to reparative tissue environment, and restoration of normal tissue structure and function. Mortality may result from deficits in these resolution mechanisms. Improved delivery of critical care through prevention of harm and removal of stimuli has already delivered significant mortality benefits. Most critically-ill patients present with uncontrolled inflammation, hence anti-inflammatory strategies ameliorating this response are likely to be too late and thus futile. Rather, strategies augmenting endogenous pathways involved in the control and appropriate curtailment of such inflammatory responses may promote resolution, repair, and catabasis. Recent evidence showing that inflammation does not simply ‘fizzle out’, but its resolution involves an active and coordinated series of events. Dysfunction of these resolution checkpoints alters the normal inflammatory pathway, and is implicated in the induction and maintenance of states such as ARDS and sepsis. Improved understanding of resolution biology should provide translational pathways to not only improve survival, but also to prevent long-term morbidity resulting from tissue damage.
Adaptive immunity in critical illness
Authors: Monaghan Sean F. , Ayala Alfred
Published: April 2016

The development of sepsis remains a significant morbid event facing the critically-ill/severely-injured patient and while substantial improvements in supportive care have been made, a true molecular pharmacological treatment directed at mitigating the development of this condition has remained elusive. This is due, at least in part, to our lack of appreciation of the complex and intertwined changes in the nature of not only the innate, but also the adaptive immune response and how they affect our response to septic challenge. Here, we consider some of the aspects of the adaptive immune response, how it changes in the response to sepsis, possible pathological processes contributing to patient/experimental animal susceptibility to poorer outcomes and where novel immune-therapeutic targets/biomarkers may exist.
Immunoparesis in the critically ill
Authors: Venet Fabienne , Lepape Alain
Published: April 2016

In parallel with an exaggerated pro-inflammatory response, critically-ill patients develop an immunosuppressive phase, termed immunoparesis/immunoparalysis or immune reprogramming. Innate and adaptive immune responses are affected. In particular, impaired neutrophil recruitment to injury sites and abnormal accumulation in remote sites; monocyte deactivation with preferential anti-inflammatory cytokine production and altered antigen presentation capacity; and a dramatic lymphopenia associated with major induction of apoptosis, functional, and phenotypic alterations have been described. The intensity and duration of this injury-induced immune dysfunction have been associated with an increased risk of death and secondary nosocomial infections. Innovative therapeutic strategies aiming at restoring immunological functions are currently being tested. GM-CSF appears to be an interesting candidate while IFN-γ‎ and IL-7 represent novel future therapeutic approaches. There is thus an urgent need for further clinical trials of such immunoadjuvant therapies that should include large cohorts of critically-ill patients stratified by relevant markers of immune dysfunction.
Decontamination and enhanced elimination of poisons
Authors: Roberts Darren M.
Published: April 2016

Decontamination and enhanced elimination are treatments that may be administered to patients with acute poisoning. They should not be used routinely in any patient, but initiated on a case-by-case basis after consideration of the type of poison, amount and time since exposure, anticipated clinical benefit, and other factors. Decontamination aims to decrease the severity and potential duration of poisoning. Activated charcoal is the most common form used and should be administered within 1–2 hours of poison ingestion. Enhanced elimination aims to decrease the duration and other consequences of poisoning. It is most commonly used for in severe poisoning with an agent that has a long elimination half-life. Elimination of a poison can be enhanced with extracorporeal therapies, multiple doses of activated charcoal, sodium polystyrene sulphate, and urinary alkalinization, although data support their use in selected cases only. To maximize poison clearance by haemodialysis or haemofiltration, the prescribed regimen may differ to that used for renal replacement therapy.
Management of opioid poisoning
Authors: Jones Alison L.
Published: April 2016

Opioids are ‘morphine like’ substances that have actions at specific opioid receptors (especially µ receptors) in the central nervous system (CNS). Tolerance of respiratory depression develops at a slower rate than analgesic tolerance, placing patients with a long history of opioid use at particular risk for respiratory depression. If chronic users abruptly stop taking opioids, they develop an acute withdrawal syndrome. Most opioid toxicity is the result of inadvertent overdosage during recreational use or in self-harm, but it can also be due to medication misuse and drug errors. It is characterized by three main clinical features (all may not be consistently present); depressed respiratory rate (the sine qua non of opioid poisoning) and respiratory volume, and reduced arterial oxygen desaturation, CNS depression, and small or pin-point pupils. Opioid-poisoned patients require early clinical assessment, appropriate administration of intravenous naloxone (competitive opioid antagonist) and meticulous respiratory supportive care, with close observation. Because of the longer half-life of opioids than naloxone, repeated doses may be needed for long-acting opioids or large doses of shorter acting opioids. If opioid antagonists are given to regular opioid users in excess, they can precipitate acute withdrawal symptoms. The need for ITU admission usually occurs as a result of a complication of the opioid toxicity.
Management of benzodiazepine poisoning
Authors: Lheureux Philippe , Van Nuffelen Marc
Published: April 2016

The wide use of benzodiazepines is associated with some inconveniences and are most frequently implicated in acute self-poisoning and accidental poisoning in children. Some of them are recognized as submission drugs, used to commit date rape or robbery. Prolonged use of a benzodiazepine leads to dependence, with a risk of developing a life-threatening withdrawal syndrome. Overdose has usually a good prognosis—most patients recover well with careful observation and prevention of complications, although care should be taken with elderly people, and patients with chronic obstructive pulmonary disease or liver dysfunction. Fast-acting agents and co-ingestion of other central nervous system depressants may be present greater risk. Early administration of activated charcoal in patients able to protect their airway is only needed if there are co-ingestants. Flumazenil may help confirm the diagnosis, improve alertness, and prevent the need for respiratory support in some patients, especially after accidental poisoning in children. Contraindications include patients on long-term treatment and/or dependent on benzodiazepines, or those who have simultaneously ingested proconvulsant or prodysrhythmic substances or at risk of increased intracranial pressure.
Management of tricyclic antidepressant poisoning
Authors: Berlot Giorgio , Tomasini Ariella
Published: April 2016

Tricyclic antidepressants (TCAs) are still prescribed worldwide for the treatment of major depression and other disorders. Unfortunately, the safety margin of these agents is rather narrow and TCA-related intoxication is associated with a number of potentially life-threatening side effects. The symptoms being rather unspecific, a high index of suspicion is warranted in order to identify promptly the intoxicated patients and to provide the appropriate care, even before the detection and dosage of TCAs and related metabolites in the blood and/or urine. In the absence of a specific antidote, the treatment basically consists in the support of ventilation in comatose patients, the correction of arterial hypotension, the treatment of arrhythmias, and the enhancement of renal excretion of TCAs.
Management of cocaine poisoning
Authors: Johnson Nicholas J. , Hollander Judd E.
Published: April 2016

Cocaine is powerful central nervous system (CNS) stimulant derived from the coca plant. It affects the body via a number of mechanisms including blockade of fast sodium channels, increased catecholamine release, inhibition of catecholamine reuptake, and increased concentration of excitatory amino acid concentrations in the CNS. It is rapidly absorbed via the aerodigestive, respiratory, gastrointestinal, and genitourinary mucosa, and also may be injected. When injected intravenously or inhaled, cocaine is rapidly distributed throughout the body and CNS, with peak effects in 3–5 minutes. With nasal insufflation, absorption peaks in 20 minutes. Its half-life is approximately 1 hour. Common clinical manifestations include agitation, euphoria, tachycardia, hyperthermia, and hypertension. Chest pain is a common presenting complaint among cocaine users; 6% of these patients will have myocardial infarction. Other life-threatening sequelae include stroke, intracranial haemorrhage, seizures, dysrhythmias, and rhabdomyolysis. Clinical signs and symptoms, as well as severity of intoxication, should dictate the diagnostic evaluation and treatment of cocaine intoxicated patients. If the patient has chest pain, an ECG, chest radiograph, and measurement of cardiac biomarkers should be performed. A brief observation period may be useful in these patients. Many manifestations of cocaine intoxication, including agitation, hypertension, and chest pain, are effectively treated with benzodiazepines. Beta-blockers should be avoided in patients with suspected cocaine intoxication. Special attention should be paid to pregnant patients and those who present after ingesting packets filled with cocaine, as they may exhibit severe toxicity if these packets rupture.
Management of cyanide poisoning
Authors: Borron Stephen W.
Published: April 2016

Acute cyanide poisoning poses vital diagnostic and therapeutic challenges for emergency physicians and intensivists. While it presents certain unique clinical features, cyanide poisoning may be confused with other entities. Definitive, contemporaneous diagnosis at the bedside is impossible in most hospitals. A thorough anamnesis, rapid physical assessment, and evaluation of key laboratory indicators often point the clinician in the right direction. Smoke inhalation from structure fires represents the most frequent source of cyanide poisoning. Symptom onset may be gradual in the case of skin exposures to cyanide or ingestion of compounds that are metabolized to cyanide. However, acute cyanide poisoning presents as a syndrome of rapidly evolving and deteriorating vital signs, profound neurological and cardiovascular dysfunction, and if therapeutic interventions are not timely and adapted, death. There is little time for diagnostic testing: one must act! The sine qua non of treatment is excellent supportive care, with aggressive airway management, support of blood pressure, and correction of acidosis. Treatment of acidosis is particularly relevant in the case of cyanide. Rapid administration of specific cyanide antidotes may be lifesaving. While geographic variations exist in antidote availability, most commercially available antidotes have been demonstrated to be effective. Hydroxocobalamin and sodium thiosulphate, both safe in the setting of smoke inhalation, offer the highest therapeutic index, a critical consideration when the diagnosis is uncertain.
Management of alcohol poisoning
Authors: Hovda Knut Erik , Jacobsen Dag
Published: April 2016

Ethyl alcohol poisoning is by far the most common alcohol poisoning, and it can usually be handled by simple symptomatic treatment. Methanol and ethylene glycol poisonings share many characteristics, often presenting with a metabolic acidosis of unknown origin. Obtaining the diagnosis could be difficult, and assays for the toxic alcohol are seldom available at hand. The diagnosis should thus be supported by the use of the anion- and osmolal gaps, and/or a simple and specific formate enzymatic method measuring the toxic metabolite itself. A delayed diagnosis of poisonings will often have fatal consequences, in spite of effective treatment available. Treatment mainly consists of buffer, antidote, haemodialysis, and folinic acid (if methanol is suspected) in addition to supportive care. The long-term prognosis of cerebral (unless hypoxic damage)—and kidney function in ethylene glycol poisonings - is good given adequate treatment. Diethylene glycol is also highly toxic, but the knowledge on toxicity is limited. We recommend treatment similar to ethylene glycol poisonings. Other alcohol poisonings are less severe, and will usually present without pronounced metabolic acidosis.
Management of corrosive poisoning
Authors: Rajagopalan Ram E.
Published: April 2016

Corrosive poisoning, typically with household chemicals, is a common problem in children and adults. As ingestion by adults is often intentional, they are usually associated with larger volumes of strong agents and have the potential to create more severe injury than that observed in the accidental ingestions commonly seen in children. The goal of acute care in these cases is to stabilize acute compromise of haemodynamics and to ensure patency of the injured airway. Blind placement of nasogastric tubes and attempts at dilution or neutralization of the ingested chemical are potentially hazardous and should be avoided. Early identification of oesophageal or gastric perforation by clinical evaluation and radiological testing will lead to early and appropriate surgical interventions for these complications. The primary focus after initial stabilization is to evaluate the extent of gastrointestinal injury by early endoscopy. The application of a standardized score to grade the injury allows risk stratification, the planning of nutritional support and referral for appropriate management of the chronic sequelae of scarring and stenosis of the injured gastrointestinal tract. No specific medical therapy can attenuate the extent of damage acutely nor alter the progression of chronic changes.
Management of vascular injuries
Authors: Gilani Ramyar , Mattox Kenneth L.
Published: April 2016

Management of vascular injuries presents a unique set of challenges. Vascular injuries are commonly accompanied by injuries to other organ systems, and affected patients may be critically ill and close to the limits of their physiological reserve. Complications of vascular injury are bleeding, leading to hypovolaemic shock and consumptive coagulopathy, and vascular occlusion causing distal ischaemia and acidosis. When the patient’s clinical condition allows the diagnosis of vascular injuries relies on computerized tomographic angiography or digital subtraction angiography. Control of haemorrhage can be achieved with direct manual pressure, tourniquets for life-threatening extremity haemorrhage, or temporary occlusion with a balloon catheter. Simple surgical repairs may be performed. Ligation is quite well tolerated for arteries of distribution. For patients with significant or ongoing bleeding, a transfusion strategy using a 1:1:1 ratio of packed red blood cells, fresh frozen plasma, and platelets is currently considered the best strategy. For more stable patients, complex and definitive vascular repairs can be considered.
Assessment and management of fat embolism
Authors: Soni Neil
Published: April 2016

Fat embolism syndrome is a complication of a range of conditions. It is hard to prevent, difficult to diagnose, and there is no specific effective treatment. The syndrome is composed of respiratory, haematological, neurological, and cutaneous symptoms and signs associated with trauma, in particular long bone fractures, and other disparate surgical and medical conditions. It most commonly follows orthopaedic surgery, but can also follow liposuction and medical conditions, as disparate as cardiopulmonary resuscitation and sickle cell disease are possible precipitants. The pathogenesis is still debated. It is clear that while fat emboli occur quite commonly, the clinical syndrome with respiratory, neurological, and other sequelae is rare. Diagnosis is by pattern recognition, but recently characteristic features seen on cerebral magnetic resonance imaging can be used to increase the probability of the diagnosis. Various therapeutic options have been tried and failed and treatment is currently supportive.
Pathophysiology of ballistic trauma
Authors: Reade Michael C. , Thomas Peter D.
Published: April 2016

Bullets and other projectiles cause ballistic trauma. Explosions wound by the effect of a blast pressure wave, penetrating fragments propelled by the explosion, the mass movement of gas interacting with the casualty or the environment, and miscellaneous effects. Most blast casualties surviving to hospital care will not have significant pressure wave injury, but some will. Blast fragmentation most commonly resembles other types of low energy transfer ballistic trauma.. The effect of bullets depends on the kinetic energy transferred and the nature of the tissues struck, with energy transfer partly determined by bullet design. Low energy transfer bullets wound by crushing and laceration, limited to the tissues struck. High energy bullets may impart kinetic energy to surrounding tissues, causing a temporary cavity which sucks in debris and damages tissues sometimes well beyond the bullet track. Predicting the extent of devitalization can be difficult at the time of initial inspection. Wound contamination, particularly with soil, may modify the usual conservative approach to initial debridement.
Assessment and immediate management of spinal cord injury
Authors: Finfer Simon , Flower Oliver
Published: April 2016

Spinal cord injury is a potentially devastating injury, which may occur in isolation, but more commonly occurs in the setting of multiple injuries. Motor vehicle accidents and falls are the most common causes. Depending on the level of the injury and its completeness, patients may be left with paraplegia or tetraplegia. The injury may be immediately obvious based on history and clinical examination, but may have to be actively excluded in multiply-injured patients. Thoracolumbar spine fractures are almost always evident on plain X-rays, whereas computed tomography (CT) or magnetic resonance imaging (MRI) is frequently required to exclude cervical spine injuries. Immediate management should be directed at the detection and treatment of life-threatening injuries. Patients should be transferred to a facility specializing in the management of spinal cord injury as soon as feasible. Acute management of the spinal injury itself is largely supportive and aimed at avoiding preventable secondary injury. Respiratory complications are common, and high thoracic or cervical injuries may lead to neurogenic shock. Early identification of the injury and appropriate management results in improved outcome, reducing disability and costs of long-term management.
Management of burns in the ICU
Authors: Shahrokhi Shahriar , Jeschke Marc G.
Published: April 2016

Outcomes of burn patients have significantly improved over the last two decades. A recent study in The Lancet showed that a burn size of over 60% total body surface area (TBSA) burned is now recognized as being associated with high risks; a decade ago similar risks resulted from a 40% TBSA burned. Similar data have been obtained in severely-burned adults and the elderly. This chapter discusses current standards, recent evidence, and future developments in burn care to improve outcomes of these patients. Critical components in the management of patients with burns are early adequate resuscitation, recognition and management of airway burns and appropriate treatment of the different stages of burn care—prehospital, early, and late management.
Pathophysiology and management of hypothermia
Authors: Ferguson Colin
Published: April 2016

Accidental hypothermia is defined as a core temperature of <35°C and is uncommon. It may present in any age group at any time of the year. Hypothermia may be primary, where the cold injury is the major pathology, or secondary where patients develop hypothermia incidental to another illness. Since the severely cold patient may be in cardiac arrest, areflexic, and in coma, decision making regarding treatment, its initiation, and continuation, may be difficult. Hypothermia is classified into mild (33–35°C), moderate (28–33°C) and severe (<28°C), but these are not distinct clinical syndromes. A more recent classification into stages has emerged from alpine medicine along with a treatment algorithm based on it. Many pathophysiogical changes are due to reduced enzyme action. Clinical features include changes in higher cerebral functions with bizarre behaviour progressing to coma. In the circulation initial tachycardia and hypertension (‘cold stress’) are replaced, as the patient cools, with worsening hypotension and bradycardia and, eventually, ventricular fibrillation and asystole. Rewarming methods are classified as passive or active and the latter subdivided into external, core, and extracorporeal. Active warming should be considered for patients with a temperature of 32°C or lower. Peritoneal lavage has the advantage of warming the liver directly and also the heart through the diaphragm. Cardiopulmonary bypass is the extracorporeal method with most experience, but the advent of extracorporeal membrane oxygenation has the advantage of portability.
Sedation assessment in the critically ill
Authors: Mistraletti Giovanni , Iapichino Gaetano
Published: April 2016

Patient comfort is a primary goal in ICU, but achieving and maintaining the appropriate balance of analgesia, sedation, and treatment of delirium is frequently challenging. International guidelines recommend keeping critically-ill patients calm and cooperative, awake in daytime and asleep at night, always avoiding deep sedation. To state the actual level of sedation and the desired one, it is necessary to frequently perform a sedation assessment with validated tools. Subjective methods are the most useful guides in ICU consciously-sedated patients, representing the gold standard for good clinical practice. Use of such a scale is a key component of sedation algorithms. The ideal scoring system should be easy, reliable, sensitive, and with minimal interobserver variability, giving no or minimal additional discomfort to the patient. Most of the proposed tools are a compromise between accuracy and time required for evaluation; the most used are the Richmond Agitation-Sedation Scale and the Sedation-Agitation Scale.
Post-operative ventilatory dysfunction management in the ICU
Authors: Chiarandini Paolo , Rocca Giorgio Della
Published: April 2016

Alterations in respiratory function and gas exchanges are frequently seen in patients during anaesthesia and in the post-operative period. Mechanical ventilation and drugs such as neuromuscular blocking agents can alter normal function of the respiratory system and cause damage to lungs. Protective ventilation strategies should always be adopted intra-operatively in mechanically-ventilated patients. A neuromuscular monitoring-guided use of decurarizating agents and post-operative adequate analgesia techniques are recommended to avoid post-operative residual curarization and pain. Pneumonia is the most frequent infective complication, but at the moment there are no recommended clinical tools (scoring systems) to identify patients at high. A fast-track surgical approach and early can decrease the risk. Early mobilization and prophylactic low molecular weight heparins use have a well-documented efficacy on prevention of pulmonary embolism. There is still no general consensus on the widespread use of early NIV in post-operative patients, although in selected high-risk patients it could help respiratory recovery and reduce complications.
Intensive care management after neurosurgery
Authors: Subhas Kamalakkannan , Smith Martin
Published: April 2016

The post-operative management of neurosurgical patients is directed towards the prevention, prompt detection, and management of surgical complications, and other factors that put the brain or spinal cord at risk. Close monitoring is required in the first 6–12 post-operative hours as deterioration in clinical status is usually the first sign of a potentially fatal complication. The majority of patients do not require complex monitoring or management beyond the first 12 hours after elective surgery, although prolonged intensive care unit management may be required for those who develop complications, or after acute brain injury. Cardiovascular and respiratory disturbances adversely affect the injured or ‘at risk’ brain, and meticulous blood pressure control and prevention of hypoxia are key aspects of management. Hypertension is particularly common after intracranial neurosurgery and may cause complications, such as intracranial bleeding and cerebral oedema, or be a consequence of them. A moderate target for glycaemic control (7.0–10 mmol/L) is recommended, avoiding hypoglycaemia and large swings in blood glucose concentration. Pain, nausea, and vomiting occur frequently after neurosurgery, and a multimodal approach to pain management and anti-emesis is recommended. Adequate analgesia not only ensures patient comfort, but also avoids pain-related hypertension. Disturbances of sodium and water homeostasis can lead to serious complications, and a structured approach to diagnosis and management minimizes adverse outcomes. Post-operative seizures must be brought rapidly under control because of the risks of secondary cerebral damage and/or progression to status epilepticus.
Intensive care management after vascular surgery
Authors: Dewhurst Alexander Timothy , Brandner Brigitta
Published: April 2016

Vascular patients require admission to an intensive care unit at a number of stages during their hospital stay. They often have multiple co-morbidities and are at risk of major complications. Their management strategy requires a multidisciplinary approach with locally agreed pathways taking national frameworks into account. Vascular emergencies require immediate resuscitation and transfer to a tertiary cardiovascular centre. Vascular disease occurs throughout the arterial vascular tree, affecting both large and small vessels. The major cause is atherosclerosis. The management of vascular conditions is complex, and includes both medical and surgical interventions. Disease can be classified as non-occlusive where there is restricted blood flow or occlusive where the vessels are completely obstructed. Aneurysmal disease occurs when vessels walls weaken. The surgical treatment of these lesions is to either replace the diseased segment of artery with a vascular graft or to exclude it with an endovascular stent. Occlusive vascular disease can occur because of atherosclerotic emboli or thrombosis, and can be treated by embolectomy, bypass, or endovascular procedures. Medical therapy with β‎-blockade, lipid-lowering agents, anti-hypertensives agents, and control of diabetes reduces cardiovascular risk. Recent advances in medical technology have shifted treatment options from open surgical to endovascular procedures. The long-term outcome and cost benefit of endovascular procedures is yet to be established.
Recovering from critical illness in hospital
Authors: Ridley Saxon
Published: April 2016

Recovery from critical illness may not be smooth and uneventful for the patient. Complications and adverse events may beset the patient and lead to intensive care unit (ICU) re-admission. Problems upsetting patients after discharge may be a manifestation of post-intensive care syndrome, new or recurrent organ failure. Avoiding post-ICU complications may be prevented by ensuring a well-planned transition from ICU to the general ward. This may be achieved by minimizing the impact and duration of organ support, defining a structured rehabilitation programme prior to ICU discharge. After discharge a short period spent on an intermediate care unit with higher nursing staff ratios, together with follow-up on the general ward will help identify and treat any new problems. Unfortunately, re-admission may be required to effectively treat some complications. There are recognized risk factors for ICU re-admission and these should be used to warn of the increased likelihood of adverse events to aid appropriate planning avoiding re-admission to ICU.
Neurocognitive impairment after critical illness
Authors: Hopkins Ramona O. , Jackson James C.
Published: April 2016

More than 5 million individuals are admitted to intensive care units (ICUs) in North America annually. Due to improvements in treatment, increasing numbers of these individuals survive and go on to develop long-term neurocognitive impairment in a variety of cognitive domains. As evidence from over two dozen studies demonstrates, neurocognitive impairment occurs in up to two-thirds of individuals. While it may be particularly common in those with pre-existing vulnerabilities, even patients who are young with robust health prior to critical illness are at risk of post-ICU neurocognitive impairment. While neurocognitive impairment may improve over time and even dissipate in a subset of ICU survivors, neurocognitive impairment is often permanent and, in some cases may be progressive. As commonly occurs in the context of acquired brain injury, the neurocognitive impairment observed after critical illness is typically diffuse, although domains including memory, attention, and executive functioning are often particularly impaired. This impairment is sufficiently severe to negatively impact daily functioning. Although the risk factors and mechanisms undergirding neurocognitive impairment have yet to be fully elucidated, potential contributors include inflammation, hypoxia, and delirium. While one way to impact on the prevalence and incidence of cognitive impairment after critical illness is to attempt to modify key ‘in-hospital’ risk factors, another approach involves the use of post-ICU cognitive rehabilitation, which is increasingly being successfully employed with other impaired medical populations.
Affective and mood disorders after critical illness
Authors: Klyce Daniel W. , Jackson James C.
Published: April 2016

Survivors of critical illness frequently have significant and persistent mental health problems, which may develop or worsen following intensive care unit (ICU) admission. Chief among these problems is depression, which occurs in approximately a third of all individuals after critical illness and is associated with a wide array of untoward outcomes. Depression is manifest in a diversity of ways and risk factors may contribute to significant depressive symptoms after critical. Questions persist about whether treatment of depression after critical illness is most effective using conventional approaches or whether the depressive symptoms observed in ICU survivors may be clinically distinct and may optimally respond to carefully tailored innovative approaches. One promising strategy for managing the mental health needs of patients after critical illness involves ICU recovery clinics, which target the unique constellation of cognitive, psychiatric, and functional challenges common to survivors of critical illness.
The ICU survivor clinic
Authors: Das Priya , Waldmann Carl
Published: April 2016

Following intensive care, patients can experience a range of long term physical and psychological effects. ICU follow-up is a continually evolving service; it can be offered as structured outpatient appointments in the year following ICU discharge, and it provides patients with individualized monitoring and supportive aftercare. For intensivists it can be an invaluable tool to facilitate continuity of care; it can help us to assess the quality of care we provide patients during ICU and to observe patient outcomes.
Post-mortem examination in the ICU
Authors: Tejerina Eva , Esteban Andrés
Published: April 2016

Autopsy has long been regarded as a valuable and reliable tool to improve quality of medical care by monitoring diagnostic accuracy and treatment of the critically-ill patients. However, post-mortem examination rates have fallen worldwide during the past decades. Unexpected findings at autopsy contribute to the increasing pool of medical knowledge and may allow the development of strategies for the early detection of diagnoses, leading to better patient care. Several studies have shown that major discrepancies are frequent, and in 5–40% of all hospitalized patients, and in 7–32% of adult intensive care patients a treatable condition that might have altered outcome, had it been recognized, is identified at post-mortem examination. Despite technological improvements in medicine, the percentage of missed diagnoses had not changed over time. Autopsy provides a ‘gold standard’ to assess the accuracy of diagnostic tests and also offers relevant information for the advance of medical knowledge and the description of new disease entities. The health care system as a whole can benefit enormously from autopsy data, the autopsy providing information unavailable by any other method, and should be considered in every patient who dies in the intensive care unit.
Hemorrhagic-Induced Cardiovascular Complications During Reamer–Irrigator–Aspirator-Assisted Femoral Nonunion Treatment
Authors: Donders Johanna C. E. , Baumann Holger M. , Stevens Markus F. , Kloen Peter
Published: April 2016

The reamer–irrigator–aspirator (RIA) is a device that has recently been developed to retrieve bone graft from the medullary canal of the femur and the tibia. As for most new surgical procedures, complications arise as part of the learning curve and/or imperfections in the design or technique. To increase awareness of potential complications and to prevent unnecessary harm to the patient, new complications need to be reported. We present case reports of 2 patients who developed severe intraoperative cardiac events presumably caused by excessive and rapid blood loss during RIA bone graft harvesting. This complication has not been described before. Increased awareness of excessive blood loss and subsequent cardiac events during an RIA procedure is warranted.

Level of Evidence:

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Culture-Negative Infection After Operative Fixation of Fractures
Authors: Gitajn Ida L. , Heng Marilyn , Weaver Michael J. , Ehrlichman Lauren K. , Harris Mitchel B.
Published: April 2016

Objectives:

(1) Compare the outcomes of patients with orthopaedic trauma with culture-negative infection with those with pathogens identified; (2) identify the incidence of culture-negative infection and describe the common characteristics.

Design:

Retrospective study.

Setting:

Two level 1 trauma centers.

Patients:

A total of 391 patients 16 years of age or older who underwent irrigation and debridement for surgical site infection after having undergone fracture fixation were included.

Intervention:

Patients underwent irrigation and debridement with cultures, and antibiotic therapy was initiated.

Main Outcome Measurement:

Treatment failure due to unsuccessful eradication of infection and time to union.

Results:

We found 9% incidence of culture-negative infection. Approximately one-third of patients in both groups went on to have treatment failure (25% of pathogen-specific infections, 38% of culture-negative infections, P = 0.15), and there was no difference between the 2 groups with regard to time to union (22 vs. 24 weeks, P = 0.55). More than one-third of patients required subsequent reconstructive procedure and 5% of patients in each group required amputation to control their infection. There was no difference between the groups with respect to the use of antibiotics before intervention and culture.

Conclusion:

This study confirms the devastating effect that postoperative infections can have and suggests that, with clinical sign of infection, negative cultures do not portend a better prognosis. These entities should be treated in a similar manner to infections with positive cultures. Furthermore, we believe that future studies should not strictly rely on the presence of positive intraoperative cultures. Consensus as to what constitutes a clinical infection, in the absence of positive cultures, is needed.

Level of Evidence:

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Embryologic and Fetal Development of the Human Eyelid
Authors: Tawfik Hatem A. , Abdulhafez Mohamed H. , Fouad Yousef A. , Dutton Jonathan J.
Published: April 2016

Purpose:

To review the recent data about eyelid morphogenesis, and outline a timeline for eyelid development from the very early stages during embryonic life till final maturation of the eyelid late in fetal life.

Methods:

The authors extensively review major studies detailing human embryologic and fetal eyelid morphogenesis. These studies span almost a century and include some more recent cadaver studies. Numerous studies in the murine model have helped to better understand the molecular signals that govern eyelid embryogenesis. The authors summarize the current findings in molecular biology, and highlight the most significant studies in mice regarding the multiple and interacting signaling pathways involved in regulating normal eyelid morphogenesis.

Results:

Eyelid morphogenesis involves a succession of subtle yet strictly regulated morphogenetic episodes of tissue folding, proliferation, contraction, and even migration, which may occur simultaneously or in succession.

Conclusions:

Understanding the extraordinary process of building eyelid tissue in embryonic life, and deciphering its underlying signaling machinery has far reaching clinical implications beyond understanding the developmental abnormalities involving the eyelids, and may pave the way for achieving scar-reducing therapies in adult mammalian wounds, or control the spread of malignancies.
Listeria monocytogenes and Prosthetic Valve Endocarditis
Authors: Best Ryan , Bhagirath Kapil M. , Pearce Stephen , Jassal Davinder S.
Published: April 2016

We report the case of a 77-year-old man presenting with bioprosthetic aortic valve endocarditis and an aortic root abscess caused by Listeria monocytogenes. The clinical presentation, treatment, and outcomes of prosthetic valve endocarditis caused by L. monocytogenes are reviewed.
Hemodynamic Bedside Ultrasound Image Quality and Interpretation After Implementation of a Training Curriculum for Pediatric Critical Care Medicine Providers*
Authors: Conlon Thomas W. , Ishizuka Maki , Himebauch Adam S. , Cohen Meryl S. , Berg Robert A. , Nishisaki Akira
Published: April 2016

Objective:

Bedside ultrasound for hemodynamic evaluation in critically ill children is increasingly recognized as an important skill for pediatric critical care medicine providers. Our institution implemented a training curriculum leading to institutional credentialing for pediatric critical care providers in nonprocedural bedside ultrasound core applications. We hypothesized that hemodynamic studies performed or supervised by credentialed providers (credentialed providers group) have better image quality and greater accuracy in interpretation than studies performed by non–credentialed providers without supervision (non–credentialed providers group).

Design:

Retrospective descriptive study.

Setting:

Single-center tertiary non-cardiac 55-bed PICU in a children’s hospital.

Patients:

Patients from October 2013 to January 2015, with hemodynamic bedside ultrasound performed and interpreted by pediatric critical care providers exposed to bedside ultrasound training.

Interventions:

A cardiologist blinded to performer scored hemodynamic bedside ultrasound image quality for five core cardiac views (excellent = 3, good = 2, fair = 1, unacceptable = 0; median = quality score) and interpretation within 5 hemodynamic domains (agreement = 3, minor disagreement = 2, major disagreement = 1; median = interpretation score), as well as a global assessment of interpretation.

Measurements and Main Results:

Eighty-one studies (45 in the credentialed providers group and 36 in the non–credentialed providers group) were evaluated. There was no statistically significant difference in quality score between groups (median: 1.4 [interquartile range: 0.8–1.8] vs median: 1.2 [interquartile range: 0.75–1.6]; p = 0.14]. Studies in the credentialed providers group had higher interpretation score than those in the non–credentialed providers group (median: 3 [interquartile range: 2.5–3) vs median: 2.67 [interquartile range: 2.25–3]; p = 0.04). Major disagreement between critical care provider and cardiology review occurred in 25 of 283 hemodynamic domains assessed (8.8%), with no statistically significant difference between credentialed providers and non–credentialed providers groups (6.1% vs 11.9%; p = 0.12).

Conclusion:

Hemodynamic bedside ultrasound performed or supervised by credentialed pediatric critical care providers had more accurate interpretation than studies performed by unsupervised non–credentialed providers. A rigorous pediatric critical care medicine bedside ultrasound credentialing program can train intensivists to attain adequate images and interpret those images appropriately.
The Blood Supply of the Breast Revisited
Authors: van Deventer Petrus V. , Graewe Frank R.
Published: April 2016

Background:

Many surgeons are under the impression that the blood supply is clearly defined in textbooks. Unfortunately, the majority of textbooks supply inadequate information and illustrations can be misleading in many instances. None of the textbooks describe a segmental pattern of blood supply when in actual fact a basic segmental pattern does exist. The reason for inadequate information is the perpetuation of facts since the work of the pioneers Cooper and Manchot from one textbook to another. A paucity of research studies thereafter and the fact that the results of some of these studies did not find their way into textbooks is another contributing factor.

Methods:

The findings of research studies since the descriptions by Cooper and Manchot are analyzed and compared in an effort to find common ground and its clinical implication.

Results:

Researchers concurred on the main sources of blood supply; these are internal thoracic, lateral thoracic, anterior intercostal, and acromiothoracic (thoracoacromial) arteries. However, the different research studies showed considerable variation in the branches from the main sources to supply the nipple-areola complex.

Conclusions:

Even though the locations of the main sources of blood supply are constant, partial or complete absence of branches from the main sources does occur and therefore the blood supply to the nipple-areola complex is unpredictable. Cognizance of the basic segmental pattern and the variations resulting from embryologic development will be helpful for the surgeon to use or adapt a technique to minimize the risk of nipple necrosis.