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Critical Care Update 2010
Vineet Nayyar, Roop Kishen, S Srinivas, John V Peter
SECTION A: LOOKING BACK
ONE:
Ten Years of the Update
INTRODUCTION
HISTORY
10 YEARS OF THE UPDATE
WHERE TO NOW
TWO:
Perceptions, Perspectives and Progress: Intensive Care 50 Years On
INTRODUCTION
IN THE BEGINNING
THE SEVENTIES AND EIGHTIES: A TIME OF MIXED BLESSINGS
THE NEXT TWO DECADES: OUR TRIUMPHS
THE LAST DECADE: OUR TRIBULATIONS
Are We Asking the Right Question?
Are the Interventions Effective?
Heterogeneous Populations and other Uncertainties
Question of Power and Severity
Other Problems with RCTs
Processes of Care
OUR FUTURE CHALLENGES
Organizational Issues
Subspecialty
Clinical Governance
Professional Responsibility
Patient Safety
CONCLUSION
AUTHOR'S NOTE
THREE:
Qualitative Synthesis of ICU Trials Over the Last Decade: Part I—Respiratory, Cardiovascular and Renal Critical Care
INTRODUCTION
SEARCH STRATEGY AND IDENTIFICATION OF STUDIES
RESPIRATORY CRITICAL CARE
Airway Related Aspects
Suctioning Related Aspects
Heat and Moisture Exchangers or Heated Humidifiers
Cuff Leak Test for Airway Obstruction
Lung Injury and Ventilation
Low Tidal Volume Ventilation and High Positive End-expiratory Pressure (PEEP)
Recruitment Maneuver
Corticosteroids
High Frequency Oscillation (HFO)
Weaning from Mechanical Ventilation
Protocolized Weaning
The Timing and Mode of Tracheostomy
Noninvasive Positive Pressure Ventilation
CARDIOVASCULAR AND RESUSCITATION ISSUES IN CRITICAL CARE
Acute Myocardial Infarction
Percutaneous Coronary Intervention
Low Molecular Weight Heparin
Right Ventricular (RV) Involvement
Intra-aortic Balloon Counter Pulsation (IABP)
Hemodynamic Monitoring
Pulmonary Artery Catheterization
Other Measurements of Cardiac Output
Intravascular Volume Assessment
Issues Pertaining to Resuscitation and Shock
Colloids vs Crystalloids
Quantitative Resuscitation
Levosimendan
Percutaneous Left Ventricular Assist Devices
RENAL CRITICAL CARE
Interventions to Prevent and Treat Acute Kidney Injury
N-acetyl Cysteine
Fenoldopam
Atrial Natriuretic Peptide
Frusemide
Interventions to Prevent Contrast Induced Nephropathy
Intravenous Sodium Bicarbonate
N-acetyl Cysteine
Theophylline
Type of Radiocontrast Dye
Renal Replacement Therapy
FOUR:
Qualitative Synthesis of ICU Trials Over the Last Decade: Part II—Nutrition, Infection, Sedation and Others
INTRODUCTION
NUTRITION ASPECTS IN CRITICAL CARE
Types of Nutritional Support and Timing
Enteral Nutrition
Timing of Nutritional Support
Enteral or Parenteral Nutrition
Gastric Versus Postpyloric Feeds
Nutritional Supplementation
Lipid Emulsion
Immunonutrition
Trace Elements
INFECTIONS IN CRITICAL CARE
Diagnostic Aspects
Interventions for Sepsis and Septic Shock
Sepsis Bundles
Corticosteroids for Sepsis and Septic Shock
Combination Antibiotic Therapy
Intravenous Immunoglobulin Therapy
Anticoagulants
Respiratory Tract Infections
Ventilator Associated Pneumonia (VAP)
Antibiotics via the Respiratory Tract
Prophylactic Therapies and Respiratory Tract Infections
Treatment of Nosocomial Pneumonia
Catheter Related Blood Stream Infections
Antifungal Therapy
SEDATION AND ANALGESIA
Propofol
Remifentanil
Dexmedetomidine
Epidural Analgesia
METABOLIC
Glycemic Control
QUALITY ISSUES
Severity Scores
Time of Admission and Staffing Levels
Daily Chest Radiography
OTHER ASPECTS
Eye Care
Interventions to Prevent Critical Illness Polyneuropathy (CIP)
Erythropoietin
LIMITATIONS
CONCLUSION
SECTION B: CARDIOVASCULAR PROBLEMS IN ICU
FIVE:
Compression Only CPR
INTRODUCTION
TRADITIONAL CPR: THE COMPRESSION TO VENTILATION RATIO
Respiratory Assistance in CPR: Limiting Factors
COMPRESSION ONLY CPR
Experimental Evidence
Clinical Evidence
CONCLUSION
SIX:
The Stent Controversy—Real or Not
INTRODUCTION
CONTROVERSIES ASSOCIATED WITH DES
Mortality Associated with DES
Stent Thrombosis
Comparison of DES with BMS
Cost-effectiveness
DES IN ACUTE MI
DES USE IN MULTI-VESSEL CAD
CONCLUSION
ABBREVIATIONS
SEVEN:
Prophylactic Use of Antifibrinolytic Drugs in Cardiac Surgery
INTRODUCTION
APROTININ
Mode of Action
Pharmacokinetics
Dosing
Potential Adverse Effects
TRANEXAMIC ACID AND EPSILON-AMINOCAPROIC ACID
Mode of Action
Pharmacokinetics
Dosing
Y
REVIEW OF EARLY YEARS OF RESEARCH
Initial Evidence
Multiple RCTs Demonstrate Efficacy of Aprotinin
Observational Studies Raise Safety Concerns
In Defence of Aprotinin
LARGE RCT—THE BART TRIAL55
POST-BART TRIAL
Observational Studies
Meta-analyses
IN SEARCH OF A ROLE FOR APROTININ IN CARDIAC SURGERY
CONCLUSION
EIGHT:
Acute Aortic Dissection
INTRODUCTION
EPIDEMIOLOGY
PATHOPHYSIOLOGY
Predisposing Conditions
CLASSIFICATION
CLINICAL FEATURES
Imaging
Biomarkers
TREATMENT
FOLLOW-UP AND OUTCOME
CONCLUSION
SECTION C: RENAL PROBLEMS IN ICU
NINE:
Does the Dose of Dialysis Affect Outcome of Patients with Acute Kidney Injury
INTRODUCTION
WHAT IS RRT DOSE AND HOW CAN WE MEASURE IT?
Efficiency
Intensity
Efficacy
WHY IS DOSE OF RRT IMPORTANT?
Effect of Dose on Clinical Outcome—What do the Studies Tell us?
What Lessons have we Learned from these Studies?
Is Our Clinical Practice Better Informed Now than Before?
CONCLUSION
Acknowledgment
Conflict of Interest
TEN:
Peritoneal Dialysis in Acute Kidney Injury
INTRODUCTION
PERITONEAL DIALYSIS AS AN OPTION IN AKI
Advantages of PD
Disadvantages of PD
PERITONEAL DIALYSIS SYSTEM
Peritoneal Membrane
Dialysate Compartment
Technical Aspects
Dialysate Composition
Intraperitoneal Hydrostatic Pressure (IPP)
PERITONEAL DIALYSIS PRESCRIPTION
Treatment Schedule
PD Exchanges
Dialysis Dose in Acute PD14
CLINICAL EFFICACY IN AKI
Effect on Mortality in AKI
Nonrenal indications
COMPLICATIONS
CONCLUSION
ELEVEN:
Acute Renal Failure in Pregnancy
EPIDEMIOLOGY
CAUSES OF ARF IN PREGNANCY
MANAGEMENT
Nondialytic Management
Dialysis
SPECIFIC OBSTETRIC DISORDERS CAUSING ARF
Pre-eclampsia
Hemolysis, Elevated Liver Enzyme Levels, Low Platelet Count (HELLP) Syndrome
Acute Fatty Liver of Pregnancy
PROGNOSIS
TWELVE:
Determinants of Circuit Life in Continuous Renal Replacement Therapy
INTRODUCTION
What is the Expected Lifespan of the Circuit?
DETERMINANTS OF CIRCUIT LIFE
Patient Factors
Vascular Access
CRRT Technique
Practice Factors
Anticoagulation Strategies
Heparins
Prostacyclin
Citrate
Other Anticoagulants
No Anticoagulation
SUMMARY
SECTION D: TRAUMA/NEUROCRITICAL CARE
THIRTEEN:
Immunomodulatory Therapies in Neurologic Critical Care
INTRODUCTION
IMMUNOMODULATORY THERAPIES
Corticosteroids
Therapeutic Plasma Exchange (TPE)
Intravenous Immunoglobulins (IVIg)
CLINICAL APPLICATIONS
Immune Mediated Neuropathies
Corticosteroids in GBS
Therapeutic Plasma Exchange
Intravenous Immunoglobulins
Myasthenia Gravis (MG)
Corticosteroids
Therapeutic Plasma Exchange
Intravenous Immunoglobulins
ADEM/Hyperacute Multiple Sclerosis (MS)
Corticosteroids
Therapeutic Plasma Exchange
Intravenous Immunoglobulins
Meningitis and Encephalitis
Primary CNS Vasculitis (PCNSV)
CONCLUSION
FOURTEEN:
Maintaining Normal Temperature after Acute Brain Injury—What Does the Evidence Say?
INTRODUCTION
ETIOLOGY OF FEVER AFTER ACUTE BRAIN INJURY
OBSERVATIONAL STUDY FROM AUSTRALIA AND NEW ZEALAND8
HYPOTHERMIA AND MAINTENANCE OF A NORMAL TEMPERATURE AFTER ACUTE BRAIN INJURY
Experimental Evidence
Hypothesis 1: Can Temperature Reduction to 32–34°C (Mild Systemic Hypothermia) Improve Clinical Outcomes after Neuronal Injury?
Hypothesis 2: Can Maintaining a Normal Temperature after Brain Injury Improve Clinical Outcomes
Data from Clinical Studies
Direct Physical Cooling of the Brain to Maintain a Normal Temperature
Maintaining a Normal Temperature with Pharmacological Agents
CONCLUSION
Acknowledgments
FIFTEEN:
Utility of Transcranial Doppler in ICU Patients
INTRODUCTION
PHYSICS OF TCD TECHNOLOGY
TECHNIQUES OF EXAMINATION
VESSEL IDENTIFICATION
TCD WAVEFORM AND INDICES OF CBF EVALUATION
CLINICAL UTILITY OF TCD
Cerebral Blood Flow Autoregulation
TCD IN SPECIFIC CLINICAL SITUATIONS
Subarachnoid Hemorrhage
Limitations of TCD in Diagnosing Vasospasm
Head Injury
Brain Death
Cerebrovascular Disease and Stroke
Detection of Microemboli
Arteriovenous Malformations
Meningitis
Sickle Cell Disease
LIMITATIONS OF TCD
CONCLUSION
SIXTEEN:
Serotonin Syndrome
INTRODUCTION
EPIDEMIOLOGY
PHYSIOLOGY OF THE SEROTONERGIC SYSTEM
PHARMACOLOGY OF SEROTONIN SYNDROME
CLINICAL FEATURES
SEVERITY OF SEROTONIN SYNDROME3
Grading of Serotonin Toxicity
Assessment of Severity
DIFFERENTIAL DIAGNOSIS4,5
Neuroleptic Malignant Syndrome
Anticholinergic Toxicity
Malignant Hyperthermia
Other Diagnoses
TREATMENT4,5
Supportive Care
Specific Therapy
CONCLUSION
SECTION E: MULTISYSTEM IMMUNOLOGICAL/HEMATOLOGICAL DISORDERS IN ICU
SEVENTEEN:
Etiopathogenesis and Management of Anaphylaxis
INTRODUCTION
Terminology
Definition
Severity Grading
ETIOLOGY
Food-induced Anaphylaxis
Drug-induced Anaphylaxis
Beta-lactams
Aspirin and Nonsteroidal Anti-inflammatory Drugs
Chemotherapy Drugs and Monoclonal Antibodies
Insect Sting (Hymenoptera) Anaphylaxis
Venom Immunotherapy
Anesthesia-related Anaphylaxis
Muscle Relaxants
Latex-induced Anaphylaxis
Exercise-induced Anaphylaxis
Idiopathic Anaphylaxis
Summation Anaphylaxis
EPIDEMIOLOGY
Worldwide Incidence
Emergency Department Presentations
Fatal Anaphylaxis
Factors Associated with Severity or Fatality
PATHOPHYSIOLOGY
Inflammatory Mast Cell and Basophil Mediators
Mediator Actions
CLINICAL FEATURES
Systemic Reaction
Myocardial Involvement
Bedside and Laboratory Investigations
Mast Cell Tryptase and Histamine
IgE Skin Testing, In Vitro Testing and Challenge Testing
MANAGEMENT
Adrenaline Dose and Route
Intramuscular Adrenaline
Intravenous Adrenaline
Nebulized Adrenaline
Fluid Replacement
Second-line Agents
H1- Antihistamines and H2- Antihistamines
Corticosteroids
Glucagon
Vasopressors
Disposition
Observation
Biphasic Anaphylaxis
Discharge Oral Medication
Self-injectable Adrenaline
Allergy/Immunology Referral
CONCLUSION
EIGHTEEN:
Thrombotic Microangiopathies
INTRODUCTION
THROMBOTIC THROMBOCYTOPENIC PURPURA (TTP)
Epidemiology
Pathophysiology
Histopathology
Clinical Features
Controversies in TTP
ADAMTS-13 Levels in TTP
TTP and HUS
Treatment
Plasma Exchange
Immunosuppression
Corticosteroids
Rituximab
Platelet Transfusions
The Future
Long-term Prognosis
HEMOLYTIC UREMIC SYNDROME (HUS)
Introduction
Clinical Features and Diagnosis
Pathophysiology
Histopathology
Treatment
Long-term Prognosis
TRANSPLANT-RELATED TMA
MULTIFACTORIAL TMA
ANTIANGIOGENIC THERAPY-RELATED TMA
PRE-ECLAMPSIA/HELLP SYNDROME
CHEMOTHERAPY-RELATED TMA
NINETEEN:
Hemophagocytic Syndrome
INTRODUCTION
PATHOGENESIS OF HEMOPHAGOCYTIC DISORDERS 6–10
CLASSIFICATION OF HEMOPHAGOCYTIC DISORDERS
Primary HS (Inherited or Familial HLH)
Infection related19
Autoimmune Disorders8
Malignancies
CLINICAL FEATURES5,6
Differences between Childhood and Adult Disease
Multiple Organ Failure5,8,35
Diagnostic Work Up
Hemophagocytosis6,34
Serum Ferritin3,36
sIL-2Rα (sCD25)38
Soluble CD16339
NK Cell Function6
Prognostication40,41
THERAPEUTIC OPTIONS IN HS6,42
Disease Specific Treatment
Corticosteroids
Intravenous Immunoglobulin (IVIg)
Cyclosporin A
Etoposide
Plasmapheresis
Anti-thymocyte Globulin (ATG)
Anti-TNF Antibody
Stem Cell Transplantation
CONCLUSION
TWENTY:
Catastrophic Antiphospholipid Syndrome: A Review
INTRODUCTION
SPECTRUM OF ANTIPHOSPHOLIPID SYNDROME
HISTORICAL FEATURES OF CAPS
ANTIPHOSPHOLIPID AUTOANTIBODIES IN CAPS AND APS
PATHOGENESIS OF APS AND CAPS
Generation of Antiphospholipid Antibodies and their Pathogenic Nature
Pathogenesis of CAPS in the Context of Antiphospholipid Antibodies
Microvascular Thrombosis
Systemic Inflammatory Response
CLINICAL PRESENTATION
Trigger Factors
General Features
Organ Specific Features
Obstetric Manifestations
DIAGNOSTIC STRATEGIES
Antiphospholipid Tests
Other Laboratory Tests
Differential Diagnoses
MANAGEMENT STRATEGIES
Anticoagulation
Corticosteroids
Plasma Exchange
Intravenous Immunoglobulin
Cyclophosphamide
Experimental Therapeutic Options
Combination Therapy
PROGNOSIS
CONCLUSION
Acknowledgment
Appendices: List of Topics Appearing in Critical Care Update 2002–2010
APPENDIX 1: CRITICAL CARE UPDATE 2002
APPENDIX 2: CRITICAL CARE UPDATE 2003
APPENDIX 3: CRITICAL CARE UPDATE 2004
APPENDIX 4: CRITICAL CARE UPDATE 2005
APPENDIX 5: CRITICAL CARE UPDATE 2006
APPENDIX 6: CRITICAL CARE UPDATE 2007
APPENDIX 7: CRITICAL CARE UPDATE 2008
APPENDIX 8: CRITICAL CARE UPDATE 2009
INDEX
TOC
Index
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