Intensive Care Fundamentals: Practically Oriented Essential Knowledge for Newcomers to ICUs

How to Use This Book?
The Origins of Intensive Care Fundamentals
How to Use This Book
Contents
Contributors
Abbreviations
I: Key Concepts in Intensive Care Medicine
1: Identification and Initial Stabilization of Acutely Deteriorated Patients
1.1 Remember Your ABCs…
1.1.1 The ABCDEF Sequence for Triage
1.1.1.1 A: Airway
1.1.1.2 B: Breathing
1.1.1.3 C: Circulation
1.1.1.4 D: Disability
1.1.1.5 E: Exposure
1.1.1.6 F: Fever
References
2: ICU Routines and Bundles of Care
2.1 ICU Ward Round and Daily Assessment (“Clerking”) of ICU Patients
2.1.1 ICU Ward Round
2.1.2 Routine Daily Assessment of the Critically Ill Patient
2.1.3 ICU Equipment and Common Problems
2.2 Fluid Therapy in the Critically Ill Patients
2.2.1 Introduction
2.2.2 Physiology of Body Fluid Compartments in Acute Illness
2.2.3 Types and Characteristics of Intravenous Fluids
2.2.4 Practical Guide to Fluid Use in ICU
2.3 Nutrition
2.3.1 Estimating the Needs: Nutritional Targets
2.3.2 Way of Delivery: Enteral vs Parenteral
2.3.3 Special Formulas and Substrates
2.3.4 Blood Glucose Control
2.3.5 Common Issues with Feeding and What To Do
2.4 Venous Thromboembolism Prophylaxis
2.4.1 Low Molecular Weight Heparins
2.4.1.1 Contraindications to Pharmacological VTE prophylaxis
2.4.1.2 Pharmacological Alternatives to LMWH
2.4.2 Mechanical Methods of Thromboprophylaxis
2.5 Positioning, Mobilization, and Rehabilitation
2.5.1 Positioning of the ICU Patient
2.5.2 ICU-Acquired Weakness
2.5.3 Protocolized Physiotherapy and Mobilization: The ABCDEF Bundle
2.6 Ventilator-Associated Pneumonia (VAP) Prevention Bundle
2.6.1 Pathophysiology and Preventability of VAP
2.6.2 Components of VAP Prevention Bundle
References
3: Intra-hospital Transport
3.1 Introduction
3.1.1 How to Do a “TEAM TIME OUT”?
3.1.2 What MONITORING Do I Need During Transport?
3.1.3 What EQUIPEMNT Do I Need to Bring on the Transport?
References
4: Human Factors and Non-Technical Skills
4.1 Introduction
4.2 Team Performance
4.3 Crisis Communication
4.4 Crisis Resource Management
4.5 Handover
4.6 Examples of Common Mistakes and Errors
References
Further Reading
5: Approach to Difficult Decisions and End-of-Life Care
5.1 Introduction
5.2 Withholding and Withdrawing Therapy
5.3 Decision-Making When Patients Lack Capacity
5.4 End-of-Life Care in ITU
5.5 Diagnosis of Death by Neurological Criteria
5.6 Organ Donation
Reference
II: Organ Dysfunction and Suppsort
6: Respiratory Failure and Respiratory Support
6.1 Introduction
6.2 Basic Physiology
6.3 Supplementary Oxygen Delivery Devices
6.4 Non-Invasive Ventilation (NIV)
6.5 Invasive Mechanical Ventilation
6.5.1 Basic Physiology of Respiratory System Related to Mechanical Ventilation
6.5.1.1 Respiratory System Compliance and Airway Resistance
6.5.1.2 Influence of Positive Pressure Ventilation on Hemodynamic Parameters
6.5.2 Basic Features of Positive Pressure Ventilators
6.5.2.1 Triggering Variables
Variables That Control Pressure Delivery
6.5.2.2 Cycling Off Variables
6.5.3 Ventilation Modes
6.5.3.1 Controlled Modes
Volume Control Mode
Pressure Control Mode
6.5.3.2 Assisted Modes of Ventilation
Pressure Support Ventilation (PSV)
BIPAP (Bilevel Positive Airway Pressure)
SIMV (Synchronized Intermittent Mandatory Ventilation)
6.5.3.3 Initial Ventilator Settings
Choosing the Mode of Ventilation
Setting FiO2
Setting PEEP
Setting Tidal Volume
6.5.3.4 Ventilatory Strategies in Specific Conditions
Ventilatory Strategies in Patients with Acute Exacerbation of COPD and Asthma
Ventilatory Strategies in Patients with ARDS
6.5.3.5 Weaning the Patient from Mechanical Ventilation
Weaning Failure
Case Vignette
Reference
Untitled
7: Shock and Haemodynamic Monitoring
7.1 Introduction
7.2 Basic Cardiovascular Physiology
7.3 Shock
7.4 Haemodynamic Monitoring
7.4.1 Lactate
7.4.2 Mixed and Central Venous Saturation, and PCO2 Gap
7.4.3 The Arterial Blood Pressure Waveform
7.4.4 Point-of-Care Ultrasound
7.4.5 Monitoring of Cardiac Output
7.5 Management of Shock
7.6 Haemorrhage
7.7 Fluid Therapy
7.8 Vasopressors and Inotropes
Further Readings
8: Disorders of Consciousness
8.1 Introduction
8.2 Approach to the Comatose Patient: Initial Resuscitation and Investigations
8.3 Pathophysiology of Raised Intracranial Pressure (ICP)
8.4 Treatment of Raised ICP
8.5 Secondary Brain Injury and Neuroprotective Measures
8.6 Specific Conditions in Neuro-Critical Care
8.6.1 Traumatic Brain Injury (TBI)
8.6.2 Subarachnoid Haemorrhage (SAH)
8.6.3 Stroke
8.6.4 Seizures and Status Epilepticus (SE)
8.6.5 Central Nervous System Infection
8.6.6 Post-Cardiac Arrest Brain Injury
8.7 Prognostication
Reference
9: Interpreting Blood Gas Analysis
9.1 Why a Blood Gas is Important in ICU?
9.2 Technical Notes to Blood Gas Measurements
9.3 How to Assess Acid-Base Status?
9.3.1 Simplified Electroneutrality-Based Method
Reference
10: Acute Kidney Injury
10.1 Introduction
10.2 Basic Renal Physiology
10.3 Assessment of Renal Function
10.3.1 Investigations
10.4 Acute Kidney Injury: Definition
10.4.1 Aetiology
10.4.2 Risk Assessment for AKI
10.4.3 Complications and Management of AKI
10.5 Renal Replacement Therapy
10.5.1 Which RRT Mode?
10.5.2 Haemofiltration vs. Haemodialysis
10.5.3 RRT Prescription
10.5.4 Stopping RRT
Case Study
Further Reading
11: Sepsis and Septic Shock
11.1 Introduction
11.2 The Definition of Sepsis and Septic Shock
11.3 Pathophysiology
11.3.1 Proinflammatory Pathways
11.3.1.1 Activation of the Endothelium
11.3.1.2 Cytopathic Hypoxia
11.3.1.3 Septic Cardiomyopathy
11.3.1.4 Endocrine Dysfunction
11.3.2 Anti-inflammatory Pathways
11.4 Diagnostics
11.4.1 Clinical Symptoms
11.4.1.1 Symptoms Related to the Source of Infection
11.4.1.2 Symptoms of Systemic Inflammation
11.4.1.3 Symptoms of Organ Dysfunction
11.4.2 Laboratory Signs of Sepsis
11.4.2.1 Specific Biomarkers
11.4.2.2 Lactate
11.5 Initial Management
11.5.1 Stabilisation of Haemodynamic Parameters
11.5.2 Early Antibiotic Therapy
11.5.3 Source Control
11.6 Follow-Up Management
11.6.1 Antibiotic Stewardship
References
III: Common Challenges and Troubleshooting in ICU
12: Hypoxia and Ventilator Asynchronies
12.1 Hypoxia
12.1.1 Basic Respiratory Pathophysiology: Five Mechanisms of Hypoxia
12.1.2 A Practical Approach to a Ventilated Patient with Worsening Hypoxia
12.1.3 Causes
12.2 Patient-Ventilator Asynchronies
12.2.1 Asynchronies During the Triggering Phase
12.2.1.1 Ineffective Efforts and Triggering Delay
12.2.1.2 Autotriggering
12.2.2 Asynchronies During the Pressure or Flow Delivery Phase
12.2.2.1 Inspiratory Airflow Asynchrony: Flow Starvation
12.2.3 Insufficient Ventilator Assist
12.2.4 Asynchronies During the Cycling-Off Phase
References
13: Arrhythmias
13.1 Introduction
13.2 Causes of Arrhythmia in ICU Patients
13.3 Arrythmia Classification
13.3.1 Tachyarrhythmias
13.3.2 Bradyarrhythmias
13.4 Initial Approach
13.5 Management of Tachyarrhythmias
13.5.1 Management of Unstable Patients with a Tachyarrhythmia
13.5.2 Management of Stable Tachyarrhythmia
13.5.2.1 Atrial Fibrillation
13.5.2.2 Supraventricular Tachycardia
13.5.2.3 Broad Complex Tachyarrhythmias
13.6 Management of Patients with Bradyarrhythmia
13.6.1 Stable Bradyarrhythmia
13.6.2 Unstable Bradyarrhythmia
Further Reading
14: An Approach to the Critically Ill Bleeding Patient
14.1 Introduction
14.2 Classification of Haemorrhage
14.3 Identification of the Source of Haemorrhage
14.4 Establishing Vascular Access
14.5 Key Resuscitation and Transfusion Principles
14.6 Resuscitation Targets in the Bleeding Patient
14.7 Correction of Factors that Contribute to Delayed Haemostasis
14.8 Reversal of Anticoagulant and Antiplatelet Agents
References
15: Analgesia and Sedation
15.1 Introduction
15.2 Pain in the ICU
15.3 Assessment of Pain in Critically Ill Patients
15.3.1 Patients, Who Can Self-Report (Conscious)
15.3.2 Patients, Who Cannot Self-Report Due to Sedation or Disorders of Brain or Mind
15.4 Assessment of Sedation in ICU Patients
15.5 Analgesia-Based Sedation/Analgosedation
15.5.1 Principles
15.5.2 Pharmacokinetic and Pharmacodynamic Considerations
15.5.3 Practical Approach to Pain Control in the ICU Patient
15.5.3.1 Modalities of Pain Management
15.5.3.2 Analgesic Drugs
15.5.4 Refractory Pain and Special Circumstances
15.5.5 Practical Approach to Sedation in ICU Patients
15.5.5.1 Principles of Sedation in ICU
15.5.5.2 Commonly Used Sedatives
15.5.5.3 Therapeutic Use of Deeper Sedation
References
16: Agitation and Delirium
16.1 Introduction
16.2 Risk Factors
16.3 Delirium Prevention
16.4 Assessment of Delirium
16.5 Bundle ABCDEF (the “ICU Liberation” Bundle)
16.6 Algorithm for the Coordinated Approach to Pain, Sedation, and Delirium in the ICU
16.7 Practical Approach to Acutely Agitated Patient in ICU
References
17: Common Electrolyte Disturbances
17.1 Diagnostic and Therapeutic Approach to Dysnatraemias
17.1.1 Key Physiological Principles
17.1.2 Hyponatraemia
17.1.2.1 Practical Diagnostic Workup
Step 1: Start with the Story
Step 2: Check Plasma Osmolality P-osm
Step 3: Determine ADH Activity by Measuring U-osm
Step 4: Assess Volume Status by Measuring UNa
Step 5: Summarise
17.1.2.2 Therapeutic Principles: Should Be Guided by Symptoms, Not Sodium Levels
17.1.3 Hypernatraemia
17.2 Disorders of Potassium Cation Concentration
17.2.1 Hypokalaemia
17.2.2 Hyperkalaemia
17.3 Magnesium
17.4 Phosphate
17.5 Calcium
References
18: Failure to Wean from Mechanical Ventilation
18.1 Introduction
18.2 Screening for Readiness
18.3 Weaning
18.3.1 Techniques
18.3.1.1 Spontaneous Breathing Trial (SBT)
18.3.2 Weaning Failure
18.3.2.1 Signs of Weaning Failure
Gas Exchange Criteria
18.3.3 Evaluate Causes of Weaning Failure
18.4 Extubation
References
Appendix A: Common ICU Drugs
Antimics
Top Ten Line Incompatibilities
Top Ten Drug–Drug Interactions
Appendix B: Useful Checklists and Algorithms
Airway Management
ICU Intubation Checklist
Difficult Airways Society Algorithm
Predicting Difficult Intubation in Critically Ill: The MACOCHA Score
Focused Ultrasound Protocols
RUSH Protocol: Rapid Ultrasound in Shock
Focused Assessment Using Sonography in Trauma (FAST)
Arrhythmias
Tachyarrhythmias Algorithm
Bradyarrhythmia Algorithm
Routine Daily Assessment Checklist
Example of Goal-Directed Mobility Protocol
Transfer of ICU Patient—Drug and Equipment Checklist
Team Emergency Assessment Measure (TEAM™)
Conversion of Urine-Specific Gravity to Urine Osmolarity
Appendix C: ICU Trainee Survival Guide