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Critical Care Update 2007
Vineet Nayyar, JV Peter, Roop Kishen, S Srinivas
SECTION A: ICU ECONOMICS
ONE:
Efficacy, Effectiveness, Efficiency and Equity
INTRODUCTION
OUTCOMES IN HEALTH CARE
EFFICACY AND EFFECTIVENESS
EFFICIENCY AND EQUITY
HEALTH CARE COSTS
CONCLUSION
TWO:
Economic Evaluation in Health Care
INTRODUCTION
HEALTH ECONOMICS- CORE CONCEPTS
Opportunity Cost
Efficiency
ECONOMIC EVALUATIONS
Incremental Cost Effectiveness Ratios (ICERs)
Costing Studies and Cost of Illness Studies
Cost Minimization Analysis (CMA)
Cost Effectiveness Analysis (CEA)
Cost Utility Analysis (CUA)
Cost Benefit Analysis (CBA)
WHAT ELSE TO LOOK FOR IN AN ECONOMIC EVALUATION?
Perspective
Is the Comparator Appropriate?
Health Outcomes
Costs (Resources)
Costs and Benefits Adjusted for Differential Timing
Considering Uncertainty
PRESENTATION AND INTERPRETATION OF RESULTS
CONCLUSION
THREE:
Cost of ICU Care in India—Prohibitive or Justified?
INTRODUCTION
HEALTH CARE EXPENDITURE IN INDIA
PROBLEMS OF COST ACCOUNTING IN INDIA
COSTING STUDIES IN ICU
Patient Related Costs or Direct Costs
Non-patient Related Costs or Indirect Costs
MEASUREMENT OF COSTS
Top-down Approach1,3,6,14
Bottom-up Approach14
COSTING STUDIES IN INDIA
CONCLUSION
FOUR:
Health Care Technology Assessment
INTRODUCTION
WHAT IS HEALTH CARE TECHNOLOGY?
HEALTH CARE TECHNOLOGY ASSESSMENT
Who are the Stakeholders in HTA?
What Risks are Associated with the Performance of an HTA?
STAGES IN THE PROCESS OF HTA
Formulation of the Policy Question
Development of the HTA Protocol
Literature Search
Possible Sources of Information include8
Data Extraction and Synthesis: Meta-analysis
Heterogeneity—Sources, Detection and Control
Modeling
Presentation and Dissemination of the HTA Report
OUTCOME MEASURES IN HTA
Outcome Measures—Economic Evaluations12,13
Outcome Measures—Efficacy and Effectiveness14,15
HOW CAN THE EFFECTIVENESS OF THE HTA PROGRAM BE ASSESSED?
WHAT DETERMINES THE TIMING OF AN HTA FOR A NEW TECHNOLOGY?
ROLE OF HTA RESOURCES ON THE INTERNET
www.inahta.org
www.euroscan.bham.ac.uk/index.htm
www.htai.org - linking to http://216.194.91.140/vortal
www.york.ac.uk/inst/crd/index.htm
www.ncchta.org
www.nice.org.uk
www.ahrq.gov
SECTION B: AIRWAY AND VENTILATION
FIVE:
Post-extubation Stridor in the ICU—A Review
INTRODUCTION
STRIDOR
RISK FACTORS
BEDSIDE ASSESSMENT OF THE AIRWAY
Cuff-leak Test
Cough on Deflation of ETT Cuff
Translaryngeal Ultrasound
Direct Visualization
TREATMENT OF POST-EXTUBATION STRIDOR
Steroids
Adrenaline
Lidocaine
Continuous Positive Airway Pressure (CPAP)
Heliox
CONCLUSION
SIX:
Mechanisms of Weaning Difficulties in Patients on Mechanical Ventilation
INTRODUCTION
CURRENT WEANING METHODS
Assessing Readiness
Weaning Trials
Removal of Endotracheal Tube
RECOGNIZE FACTORS THAT DELAY WEANING
Absence of a Standardized Weaning Procedure
Excessive Ventilatory Assistance
Staff Shortages
Oversedation
CAUSES OF WEANING DIFFICULTIES
Cardiorespiratory Causes
Neuromuscular Weakness
Other Causes of Prolonged Dependence on the Ventilator
ROLE OF TRACHEOSTOMY IN WEANING
CONCLUSION
SEVEN:
Open versus Closed Suctioning—Does it Make A Difference?
INTRODUCTION
Methods of Endotracheal Suctioning
METHODOLOGY
RESULTS
Clinical Outcomes
Physiological Outcomes
Microbiological Outcomes
Technique Related Outcomes
Costs
DISCUSSION
EIGHT:
Oral Hygiene in Intubated Mechanically Ventilated Patients
INTRODUCTION
ORAL HEALTH AND SYSTEMIC DISEASE
ORAL HYGIENE
BARRIERS TO ORAL HYGIENE IN INTENSIVE CARE
Physical Barriers
Lack of Good Quality Evidence
Perception and Communication Barriers
ORAL HYGIENE TOOLS AND SOLUTIONS
Mechanical Oral Hygiene Tools
Mouth Rinses
After Care
CONCLUSION
SECTION C: ICU PHYSIOLOGY AND PHARMACOLOGY
NINE:
Natriuretic Peptide Physiology in the ICU
INTRODUCTION
HEART FAILURE
OTHER CARDIOVASCULAR DISEASES
SEPSIS
PULMONARY EMBOLISM (PE)
CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)
RENAL FAILURE
FLUID ADMINISTRATION
CONCLUSION
TEN:
Acid-base Physiology—The Modern Approach
INTRODUCTION
TRADITIONAL APPROACH
Limitations of Traditional Approach
Buffer Base, Standard Bicarbonate and Base Excess
The Anion Gap
STEWART (MODERN) APPROACH
Basic Principles of Stewart Approach
Application of Stewart Approach
Interpreting Acid-base Disorders using Stewart Model at the Bedside
Examples
Ion Equilibrium Theory17
LEARNING POINTS – ACID-BASE INTERPRETATION MADE EASY
CONCLUSION
ELEVEN:
Cytokine Physiology of Sepsis
INTRODUCTION
CYTOKINES IN INFLAMMATION AND HEALTH
INFECTION INDUCED SYSTEMIC CYTOKINE DYSREGULATION
Acute Phase Responses to Infection
Cytokine Storm in Sepsis
Dysregulated Systemic Inflammation in Sepsis
Organ Dysfunction-Adaptation or Malfunction?
EMERGING AREAS
Central Nervous System Control of Cytokine Production
Application of Technologies Emerging from Molecular Biology
Areas of Clinical Significance
CONCLUSION
TWELVE:
Adrenocortical Physiology in Critical Illness
INTRODUCTION
REVIEW OF CORTISOL PHYSIOLOGY
Response of HPA to Critical Illness
STEROID THERAPY IN SEPSIS
Why have trials on steroid therapy in septic shock failed?
LIMITATIONS OF THE CURRENT APPROACH
Use of Total Plasma Cortisol for Diagnosing RAI
Use of Corticotropin Stimulation Test (CST) for Diagnosing RAI
Use of Commercially Available Cortisol Kits
Lack of Data on Free Cortisol
POTENTIAL USE OF TISSUE CORTISOL ACTIVITY
CONCLUSION
SECTION D: SEPSIS AND INFECTION CONTROL
THIRTEEN:
Is Adrenaline Effective in Septic Shock?
INTRODUCTION
HEMODYNAMIC CHANGES IN SEPSIS
EVIDENCE FOR CATECHOLAMINES IN SEPTIC SHOCK
Effect on Vasculature
Cardiac Output
ADRENALINE IN SEPTIC SHOCK
Observational Studies
Randomized Control Trials
Meta-analysis
Evidence to Support use of Adrenaline
CONCLUSION
FOURTEEN:
Role of Antimicrobials in Severe Acute Pancreatitis
INTRODUCTION
PATHOPHYSIOLOGY OF INFECTION
PREVENTION OF INFECTION
Prophylactic Antibiotics
Use of Selective Decontamination
MANAGEMENT OF INFECTED NECROSIS
Diagnosis
Treatment
CONCLUSION
FIFTEEN:
Newer Antistaphylococcal Agents
INTRODUCTION
STAPHYLOCOCCAL INFECTION
Epidemiology of Staphylococcal Infection
Methicillin-resistant Staphylococcus aureus
REAPPRAISAL OF EXISTING AGENTS
Linezolid
Quinupristin-Dalfopristin
Daptomycin
Tigecycline
Telithromycin
DRUGS UNDER INVESTIGATION
Oritavancin
Dalbavancin
Telavancin
Ceftobiprole
Garenoxacin
Iclaprim
Faropenem
NOVEL METHODS
CONCLUSION
SIXTEEN:
Significance of Acinetobacter in the ICU
INTRODUCTION
ACINETOBACTER BAUMANNI IN THE ICU
Survival
Mechanisms of Resistance
Infection and Risk Factors
CLINICAL DISEASE
Diagnosis
Therapeutic Options for Nosocomial A. baumannii
Attributable Mortality
CONTROL MEASURES
Outbreak
Controlling Transmission
CONCLUSION
SECTION E: DIAGNOSTICS AND MONITORING
SEVENTEEN:
Ventilator Graphics—One more Screen in a Modern ICU
INTRODUCTION
FUNDAMENTAL GRAPHICS – SCALARS (1)
Flow-time Curve (Figs 17.1 and 17.2)
Pressure-time Curve (Figs 17.3 and 17.4)
FUNDAMENTAL GRAPHICS – LOOPS1
Pressure-volume loops (Figs 17.5 and 17.6)
The Dynamic P-V Loop
The “Quasi-static” (low, constant-flow) P-V Loop (2)
Flow-volume Loops
PRACTICAL UTILITY OF GRAPHIC WAVEFORMS
Graphics and Patient-ventilator Asynchrony
Graphics in the Management of Obstructive Airways Disease (OAD)
Graphics in ARDS—The Current Status P-V Loops
CONCLUSION
EIGHTEEN:
Where does Gastric Tonometry Stand Today?
INTRODUCTION
PHYSIOLOGY PERTAINING TO GASTRIC TONOMETRY
Relationship of Blood Flow to Tissue CO2
Tissue CO2 Production
TECHNIQUE OF GASTRIC TONOMETRY
Saline Tonometry
Air Tonometry
pHi, PgCO2, and the CO2 gap
VALIDATION OF GASTRIC TONOMETRY
CLINICAL USE OF GASTRIC TONOMETRY
Use in Prognostication
Cardiac Surgery
Major Vascular Surgery
High-risk Surgery
Trauma
General Critical Care
Sepsis, Acute Pancreatitis, Mechanical Ventilation
Use in Therapeutic Interventions
CONCLUSION
NINETEEN:
Biomarkers of Sepsis
INTRODUCTION
WHAT IS A MARKER?
MARKERS OF SEPSIS
C-Reactive Protein
Procalcitonin
PCT in Different Clinical Situations
PCT in Comparison to CRP
Results of Meta-Analyses
Triggering Receptor Expressed on Myeloid Cells-1
OTHER MARKERS OF INFECTION
Endotoxin Activity Assay
Adrenomedullin
Natriuretic Peptides
Lipopolysaccharide-Binding Protein
Endocan
Complement 3a
Neopterin
Growth Arrest Specific Protein
Urinary Biomarker
CONCLUSION
TWENTY:
Capnography in the Intensive Care Unit
INTRODUCTION
CO2 MEASUREMENT—PHYSIOLOGY AND PHYSICS
CO2 Elimination and Its Relation to Arterial CO2
Methods of CO2 Measurement
Capnometry
Capnography
ANALYSIS OF CAPNOGRAPHY
Time Capnogram
Volume Capnography
UTILITY OF CAPNOGRAPHY IN INTENSIVE CARE
Endotracheal Intubation
Feeding Tube Insertion
Transport of Critically Ill Patients
Adequacy of Cardiopulmonary Resuscitation
Pulmonary Embolism
Assessing Metabolic Acidosis
UTILITY OF CAPNOGRAPHY DURING MECHANICAL VENTILATION
Dead Space Measurement and PEEP Titration in ARDS
Weaning and Extubation
CONCLUSION
INDEX
TOC
Index
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