Intensive Care Management Of Patients Research Articles

Management of Severe Hypercapnia Post Cardiac Arrest with Extracorporeal Carbon Dioxide Removal

Normocapnia is recommended in intensive care management of patients after out-of-hospital cardiac arrest. While normocapnia is usually achievable, it may be therapeutically challenging, particularly in patients with airflow obstruction. Conventional mechanical ventilation may not be adequate to provide optimal ventilation in such patients. One of the recent advances in critical care management of hypercapnia is the advent of newer, low-flow extracorporeal carbon dioxide clearance devices. These are simpler and less invasive than conventional extracorporeal devices. We report the first case of using a novel, extracorporeal carbon dioxide removal device in Australia on a patient with out-of-hospital cardiac arrest where mechanical ventilation failed to achieve normocapnia.

Specific intensive care management of patients with traumatic brain injury: Present and future.

Traumatic brain injury (TBI) is a major global problem and affects approximately 10 million peoples annually; therefore has a substantial impact on the health-care system throughout the world. In this article, we have summarized various aspects of specific intensive care management in patients with TBI including the emerging evidence mainly after the Brain Trauma Foundation (BTF) 2007 and also highlighted the scope of the future therapies. This review has involved the relevant clinical trials and reviews (from 1 January 2007 to 31 March 2013), which specifically discussed about the topic. Though, BTF guideline based management strategies could provide standardized protocols for the management of patients with TBI and have some promising effects on mortality and morbidity; there is still need of inclusion of many suggestions based on various published after 2007. The main focus of majority of these trials remained to prevent or to treat the secondary brain injury. The future therapy will be directed to treat injured neurons and may benefit the outcome. There is also urgent need to develop some good prognostic indicators as well.

Delayed intensive care unit admission is associated with increased mortality in patients with cancer with acute respiratory failure

Acute respiratory failure (ARF) is the leading reason for intensive care unit (ICU) admission in patients with cancer. The aim of this study was to identify early predictors of death in patients with cancer admitted to the ICU for ARF who were not intubated at admission. We conducted analysis of a prospective randomized controlled trial including 219 patients with cancer with ARF in which day-28 mortality was a secondary endpoint. Mortality at day 28 was 31.1%. By multivariate analysis, independent predictors of day-28 mortality were: age (odds ratio [OR] 1.30/10 years, 95% confidence interval [CI] [1.01–1.68], p = 0.04), more than one line of chemotherapy (OR 2.14, 95% CI [1.08–4.21], p = 0.03), time between respiratory symptoms onset and ICU admission > 2 days (OR 2.50, 95% CI [1.25–5.02], p = 0.01), oxygen flow at admission (OR 1.07/L, 95% CI [1.00–1.14], p = 0.04) and extra-respiratory symptoms (OR 2.84, 95%CI [1.30–6.21], p = 0.01). After adjustment for the logistic organ dysfunction (LOD) score at admission, only time between respiratory symptoms onset and ICU admission > 2 days and LOD score were independently associated with day-28 mortality. Determinants of death include both factors non-amenable to change, and delay in ARF management. These results suggest that early intensive care management of patients with cancer with ARF may translate to better survival.

Aneurysmatisch bedingte Subarachnoidalblutung

Acute subarachnoid hemorrhage (SAH) is a severe and acute life-threatening cerebrovascular disease. Approximately 80% of all acute non-traumatic SAHs are the result of a ruptured cerebrovascular aneurysm. Despite advances in diagnosis and treatment a high morbidity and mortality still exists. Apart from the primary cerebral damage there are also secondary complications, such as vasospasm, rebleeding, hydrocephalus, cerebral edema or hydrocephalus. For an appropriate therapy an understanding of the extensive pathophysiology, the options in diagnostics and therapy and the complications of the disease are essential. Anesthesiologists are decisively involved in the therapy of the primary and secondary damages and subsequently in the outcome as well. This article provides an overview of the perioperative and intensive care management of patients with SAH.

Elevation of the head during intensive care management in patients with severe traumatic brain injury

Elevation of the head during intensive care management in patients with severe traumatic brain injury

Anesthetic management in patients undergoing hyperthermic chemotherapy

Cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (HIPEC) has become an important therapeutic option for selected patients with peritoneal surface malignancies. This aggressive multimodality treatment is complex, not only regarding surgical technique, but also regarding anesthesia. The present review represents our experience in anesthetic care. Improved prognosis compared with systemic chemotherapy alone has recently been demonstrated for cytoreductive surgery when combined with intraoperative intracavitary hyperthermic chemotherapy. Anesthetic management of HIPEC is further impacted by these developments. In addition to the ambitious, long-lasting surgery, HIPEC causes significant fluid, blood and protein losses, increased intra-abdominal pressure, systemic hyperthermia, and increased metabolic rate, leading to relevant pathophysiological alterations, and therefore represents a challenge for anesthetist and critical care physicians. Anesthetic management importantly contributes to the containment of the perioperative complications of HIPEC. An appreciation of the technical aspects and physiologic disruptions associated with intra-abdominal HIPEC is critical to ensure effective anesthetic management. Although data on this specialized surgical procedure are scarce, some referral centers have accumulated extensive experience. This article reviews the current knowledge about the anesthesiological and intensive care management of patients undergoing HIPEC. It pinpoints strategies for perioperative monitoring as well as illustrates alterations in hemodynamic, hematopoetic, and fluid hemostasis.

Der Patient mit implantiertem Device in der Intensivmedizin

The management of intensive care patients with implanted devices requires the knowledge of the type of device (e.g. pacemaker, defibrillator, device for cardiac contractility modulation or event recorder). An electrocardiogram (ECG) and chest-X-ray can be helpful for identification of the type and manufacturer of the device. Information concerning the programmed parameters can be obtained by device interrogation. The establishment of invasive monitoring can be complicated by the intracardiac electrodes of the devices and requires a careful selection of the venous access site. In cases of external cardioversion/defibrillation there are some specific considerations to be made to avoid damage of the implanted device. Finally, adaption of device programming to the special circumstances in the intensive care unit may help patient and physician.

From system to organ to cell: oxygenation and perfusion measurement in anesthesia and critical care

Maintenance or restoration of adequate tissue oxygenation is a main goal of anesthesiologic and intensive care patient management. Pathophysiological disturbances which interfere with aerobic metabolism may occur at any stage in the oxygen cascade from atmospheric gas to the mitochondria, and there is no single monitoring modality that allows comprehensive determination of “the oxygenation”. To facilitate early detection of tissue hypoxia (or hyperoxia) and to allow a goal directed therapy targeted at the underlying problem, the anesthesiologist and intensive care physician require a thorough understanding of the numerous determinants that influence cellular oxygenation. This article reviews the basic physiology of oxygen uptake and delivery to tissues as well as the options to monitor determinants of oxygenation at different stages from the alveolus to the cell.

Lesões cerebrais agudas e sua influência sobre a motilidade gastrintestinal

Subarachnoid hemorrhage can increase intracranial pressure, causing significant morbidity. Acute gastric dilation and delayed gastric emptying are commonly seen in patients with intracranial hypertension, and correction of these gastric abnormalities can facilitate the recovery of patients with brain injuries. We conducted a literature review of both national and international health sciences medical journals and electronic libraries spanning the last twenty-eight years and focused on the brain, gut motility and gastric emptying functional axis either in experimental animal models of brain injury or patients with acute cerebral injuries. Decreased parasympathetic tonus is a potential cause of intracranial hypertension-related food intolerance. Changes in gastrointestinal transit after a brain injury follow a biphasic pattern: an initial phase of accelerated gastric emptying and a late stage of intestinal lethargy. Changes in the physiology underlying gut motility may be essential for homeostatic stabilization in hemodynamically unstable patients. Research studies are necessary to understand the difficult management of intensive care patients with intracranial hypertension secondary to subarachnoid hemorrhages resulting from traumatic brain injuries or rupture of a cerebral aneurysm. Increased intracranial pressure induces massive increases in sympathetic activity, which is responsible for many of the peripheral systemic and gastrointestinal symptoms. Brain injuries leading to significant increases in intracranial pressure result in delayed gastrointestinal emptying due to autonomic nervous system changes.

Hemodynamic Monitoring Today

Hemodynamic monitoring has been part of the routine management of intensive care patients and high risk surgical patients since the advent of the pulmonary artery catheter (PAC) more than thirty years ago. The growing availability of new less invasive devices over the past decades has now made it possible to monitor cardiac output (CO) more often in the operating room, as well as in new clinical settings such as the emergency department. In this special issue papers have been arranged that discuss different aspects of hemodynamic monitoring, from technical issues to new clinical applications. The first paper titled “Perioperative intravascular fluid assessment and monitoring: a narrative review of established and emerging techniques” is a review on perioperative intravascular fluid assessment and monitoring. How cardiovascular physiology can be monitored is explained, and different technologies are presented. The second paper titled “Cardiac output assessed by invasive and minimally invasive techniques” is a review on all available technologies to monitor CO. The authors start from the PAC and carry on to present the more recent less invasive devices. The review covers technical aspects as well as clinical validation and use. The third paper titled “The effect of a hyperdynamic circulation on tissue Doppler values: a simulation in young adults during exercise” presents research done on healthy individuals undergoing strenuous exercise, using left ventricular tissue Doppler velocity (TDI), giving us new data on the use of TDI in hyperdynamic circulation. The fourth paper titled “The effect of airway pressure release ventilation on pulmonary catheter readings: specifically pulmonary capillary wedge pressure in a swine model” investigates the effect of the airway pressure release ventilation (APRV) on the PAC readings in an animal model. This papers gives new insights into the heart-lung interaction when using this new mode of ventilation. In the fifth paper titled “Clinical applications of heart rate variability in the triage and assessment of traumatically injured patients” heart rate variability (HRV) is explored. HRV represents a way of looking at the function of autonomic nervous system during stress conditions and has been studied in different areas as a predictor of morbidity and mortality. In this paper the authors focus on the use of HRV in trauma patients. The sixth paper titled “Recommendations for haemodynamic and neurological monitoring in repair of acute type A aortic dissection” gives a perspective on how hemodynamic monitoring should be used in conjunction with other clinical strategies. In this review the authors describe how hemodynamic monitoring can be combined with neurological monitoring in order to optimize the circulation guaranteeing adequate cerebral blood flow. The seventh paper titled “Assessing the left ventricular systolic function at the bedside: the role of transpulmonary thermodilution-derived indices” is a review on the use of transpulmonary thermodilution to measure CO and other derived variables. The authors focus on how these variables can be used to assess the left ventricular function in different clinical situations. Maurizio Cecconi Jamal A. Alhashemi Maxime Cannesson Christoph K. Hofer

Intensive care management of patients with haematological malignancy

Serious complications are common among patients admitted to hospital with a diagnosis of haematological malignancy, with one British study of 1437 admissions identifying 7% as being complicated by an episode of critical illness. Although most of these episodes did not result in admission to intensive care unit (ICU), an increasing number of patients with a diagnosis of haematological malignancy are being managed within ICU or are receiving critical care input. Complication rates are higher for posthaematopoietic stem cell transplant (HSCT) patients with a recent abstract revealing an overall ICU admission rate for transplant patients of 13.6% among 1671 British patients over a 10 yr period. ICU admission for patients with haematological malignancies, and particularly after bone marrow transplantation, has been associated with very poor outcomes, and in some cases, critical care has been withheld because it was perceived to be futile. Newer studies suggest that ICU outcomes have improved, probably as a result of changes in both haematological treatments and ICU care. Patients with haematological malignancy may develop critical illness either as part of their first presentation with the malignancy or more commonly after chemotherapy or HSCT. Some presentations are specific to each scenario, whereas others may occur in all groups of patients. Respiratory failure is present in approximately half of all referrals to ICU. Between 10% and 50% of the patients have signs of shock, and there is evidence of multiple organ failure in about onefifth. Other causes for admission include neurological failure, gastrointestinal (GI) bleeding, renal failure, and metabolic derangement.

Critical Care of Myasthenia Gravis in a Resource Poor Setting

Myasthenia gravis presenting as a neurologic emergency warrants management in a critical care unit. In resource poor settings which typify much of Africa, this can be very challenging even in tertiary centers with consequently unfavorable outcomes. This study evaluated the outcomes of intensive care management of patients with myasthenia gravis in a regional teaching hospital in South East Nigeria. A retrospective study was undertaken of patients admitted into the intensive care unit of the University of Nigeria Teaching Hospital Enugu, South East Nigeria, with myasthenia gravis as a neurologic emergency. This study covered a 13-year period from 1992 to 2004. From the case records demographic data, clinical features and details of clinical management, complications, and outcomes were determined and subjected to analysis. The median age at presentation was 29 years (range, 20 to 42 y) with male:female ratio of 1:2.7. The median duration of illness before presentation to the intensive care unit was 7 months (range, 1 wk to 3 y). The median duration of stay in the unit was 15 days (range, 1 to 36 d). Two cases of septicemia and acute renal failure were recorded. The overall mortality rate was 27.3%. Sepsis is a major factor contributing to poor outcomes among patients with myasthenia gravis managed in critical care units in Nigeria. Vigorous and concerted efforts should be made to make intensive care units more effective in Africa.

Intensive care management of patients with acute intermittent porphyria: Clinical report of four cases and review of literature

Acute intermittent porphyria (AIP), the most common and the most severe form of acute hepatic porphyria, is an autosomal dominant condition. It results from lower-than-normal levels (less than 50%) of porphobilinogen (PBG) deaminase. Patients may present commonly with gastrointestinal complaints and neuropsychiatric manifestations. Diagnosis may be confirmed with the presence of intermediary metabolites of haem synthesis, amino levulinic acid (ALA) and PBG in urine or with specific enzyme assays. Abdominal pain is the most common symptom (90%). Peripheral polyneuropathy, primarily motor with flaccid paresis of proximal musculature, with or without autonomic involvement, is characteristic. Respiratory failure necessitates ventilator and intensive care support. Avoidance of precipitating factors and the use of haem preparations and intravenous dextrose form the basis of management. Gabapentin and propofol, rather than the conventional antiepileptics appear to be the appropriate choice for seizure control. Here, we present intensive care management of four cases of AIP with varying clinical presentation.

Intensive Care Unit Management of Status Asthmaticus

In Brief Patients with severe asthma exacerbations, status asthmaticus (SA), or near-fatal asthma, account for almost 2 million emergency department visits annually in the United States, 497,000 hospital admissions, and 5000 deaths. Approximately, 2% to 70% (mean, 30%) of ICU admissions for asthma require mechanical ventilation, and the mortality rate of mechanically ventilated patients can range from 6% to 42% in high-risk populations. Risk stratifying patients presenting with a severe exacerbation is difficult. In this article, the pathophysiology of near-fatal asthma and SA is reviewed. Many patients who died of SA lack the typical risk factors for death. The 2 phenotypes of severe asthma (acute and subacute onset) are similar with respect to presenting signs but their demographics and rate of decline differ after illness onset. The clinical evaluation and risk stratification of patients presenting with severe asthma exacerbations are a vital and challenging component of their care. The rational use of inhaled and systemic therapies is also required to minimize complications and maximize benefits. Strategies for the use of mechanical ventilation that minimize the risk of barotrauma and use of permissive hypercapnia are a key to reduce mortality. The use of extrinsic positive end expiratory pressure is not contraindicated and may benefit a subset of patients. At this time, the use of noninvasive mechanical ventilation in the most severe asthma exacerbations cannot be recommended. The use of sedatives, inhalational anesthetics, and paralytics as adjuncts to mechanical ventilation have potential risks and their use must be individualized. Status asthmaticus and near fatal asthma are life-threatening entities. The care requires an assessment of risk and, often, a critical care environment. This review discusses the intensive care management of patients presenting with severe asthma exacerbations.

Management of acute liver failure

Acute liver failure (ALF) is a syndrome of diverse etiology, in which patients without previously recognized liver disease sustain a liver injury that results in rapid loss of hepatic function. Depending on the etiology and severity of the insult, some patients undergo rapid hepatic regeneration and spontaneously recover. However, nearly 60% of patients with ALF in the US require and undergo orthotopic liver transplantation or die. Management decisions made by clinicians who initially assess individuals with ALF can drastically affect these patients' outcomes. Even with optimal early management, however, many patients with ALF develop a cascade of complications often presaged by the systemic inflammatory response syndrome, which involves failure of nearly every organ system. We highlight advances in the intensive care management of patients with ALF that have contributed to a marked improvement in their overall survival over the past 20 years. These advances include therapies that limit the extent of liver injury and maximize the likelihood of spontaneous recovery and approaches to enable prevention, recognition and early treatment of complications that lead to multi-organ-system failure, the most common cause of death. Finally, we summarize the role of orthotopic liver transplantation in salvage of the most severely affected patients.

Accuracy and precision of a novel non-invasive core thermometer

Accurate measurement of core temperature is a standard component of perioperative and intensive care patient management. However, core temperature measurements are difficult to obtain in awake patients. A new non-invasive thermometer has been developed, combining two sensors separated by a known thermal resistance ('double-sensor' thermometer). We thus evaluated the accuracy of the double-sensor thermometer compared with a distal oesophageal thermometer to determine if the double-sensor thermometer is a suitable substitute. In perioperative and intensive care patient populations (n=68 total), double-sensor measurements were compared with measurements from a distal oesophageal thermometer using Bland-Altman analysis and Lin's concordance correlation coefficient (CCC). Overall, 1287 measurement pairs were obtained at 5 min intervals. Ninety-eight per cent of all double-sensor values were within +/-0.5 degrees C of oesophageal temperature. The mean bias between the methods was -0.08 degrees C; the limits of agreement were -0.66 degrees C to 0.50 degrees C. Sensitivity and specificity for detection of fever were 0.86 and 0.97, respectively. Sensitivity and specificity for detection of hypothermia were 0.77 and 0.93, respectively. Lin's CCC was 0.93. The new double-sensor thermometer is sufficiently accurate to be considered an alternative to distal oesophageal core temperature measurement, and may be particularly useful in patients undergoing regional anaesthesia.

Critical care management of subarachnoid hemorrhage

Successful critical care management of patients with aneurysmal subarachnoid hemorrhage (SAH) requires a thorough understanding of the disease and its complications and a familiarity with modern multimodality neuromonitoring technology. This article reviews the natural history of aneurysmal SAH and strategies for disease management in the acute setting, including available tools for monitoring brain function. Intensive care management of patients with SAH focuses on prevention of further neurologic injury. Aneurysmal rebleeding, hydrocephalus, seizures, and delayed ischemic injury represent major threats. There is increasing awareness of extracerebral complications, including electrolyte disturbances (eg, cerebral salt wasting) and cardiac dysfunction. Prompt recognition and treatment of these disorders maximizes the odds of a good functional outcome. Technologic advances hold the promise of improved detection and treatment of secondary neurologic insults.

Critical care nurses’ decision making: sedation assessment and management in intensive care

This study was designed to examine the decision making processes that nurses use when assessing and managing sedation for a critically ill patient, specifically the attributes and concepts used to determine sedation needs and the influence of a sedation guideline on the decision making processes. Sedation management forms an integral component of the care of critical care patients. Despite this, there is little understanding of how nurses make decisions regarding assessment and management of intensive care patients' sedation requirements. Appropriate nursing assessment and management of sedation therapy is essential to quality patient care. Observational study. Nurses providing sedation management for a critically ill patient were observed and asked to think aloud during two separate occasions for two hours of care. Follow-up interviews were conducted to collect data from five expert critical care nurses pre- and postimplementation of a sedation guideline. Data from all sources were integrated, with data analysis identifying the type and number of attributes and concepts used to form decisions. Attributes and concepts most frequently used related to sedation and sedatives, anxiety and agitation, pain and comfort and neurological status. On average each participant raised 48 attributes related to sedation assessment and management in the preintervention phase and 57 attributes postintervention. These attributes related to assessment (pre, 58%; post, 65%), physiology (pre, 10%; post, 9%) and treatment (pre, 31%; post, 26%) aspects of care. Decision making in this setting is highly complex, incorporating a wide range of attributes that concentrate primarily on assessment aspects of care. Clinical guidelines should provide support for strategies known to positively influence practice. Further, the education of nurses to use such guidelines optimally must take into account the highly complex iterative process and wide range of data sources used to make decisions.

Critical Management Decisions in Patients With Acute Liver Failure

Few admissions to the ICU present a greater clinical challenge than the patient with acute liver failure (ALF), the syndrome of abrupt loss of liver function in a previously unaffected individual. Although advances in the intensive care management of patients with ALF have improved survival, the prognosis of ALF remains poor, with a 33% mortality rate and a 25% liver transplant rate in the United States. ALF adversely affects nearly every organ system, with most deaths occurring from sepsis and subsequent multiorgan system failure, and cerebral edema, resulting in intracranial hypertension (ICH) and brainstem herniation. Unfortunately, the optimal management of ALF remains poorly defined, and practices are often based on local experience and case reports rather than on randomized, controlled clinical trials. The paramount question in any patient presenting with ALF remains defining an etiology, since specific antidotes can save lives and spare the liver. This article will consider recent advances in the assignment of an etiology, the administration of etiology-specific treatment to abate the liver injury, and the management of complications (eg, infection, cerebral edema, and the bleeding diathesis) in patients with ALF. New data on the administration of N-acetylcysteine to patients with non-acetaminophen ALF, the treatment of ICH, and assessment of the need for liver transplantation will also be presented.

Assessment of cerebrovascular resistance with a model of cerebrovascular pressure transmission

A method to assess continuous changes of cerebrovascular resistance based on a biomechanical model of cerebrovascular pressure transmission is developed. Such a method provides an end-point measure to assess new and/or existing management strategies during intensive-care management of patients with brain injury. Changes of both pial arteriolar resistance and cerebrovascular resistance derived by a physiologically based biomechanical model of cerebrovascular pressure transmission, the dynamic relationship between arterial blood pressure (ABP) and intracranial pressure (ICP), were compared to test the validity of the modeling procedure. Pressor challenge was administered to normoxic ( N = 5) and hypoxic ( N = 5) piglets equipped with closed cranial windows. Pial arteriolar diameters were used to compute arteriolar resistance. Percent change of pial arteriolar resistance (%ΔPAR) and percent change of model-derived cerebrovascular resistance (%ΔsCVR) in response to pressor challenge were computed. During intact cerebrovascular regulation and during hypoxia-induced impairment of cerebrovascular regulation, changes in pial arteriolar resistance were accurately predicted by the proposed modeling method designed to assess changes of cerebrovascular resistance.