Core knowledge in critical care medicine 2016

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Core Knowledge in Critical Care Medicine Wolfgang Krüger Andrew James Ludman 123 Core Knowledge in Critical Care Medicine Wolfgang Krüger • Andrew James Ludman Core Knowledge in Critical Care Medicine Wolfgang Krüger Medizinische Universitätsklinik Kantonsspital Aarau Aarau Switzerland Andrew James Ludman Department of Cardiology The London Chest Hospital London UK ISBN 978-3-642-54970-0 ISBN 978-3-642-54971-7 DOI 10.1007/978-3-642-54971-7 Springer Heidelberg New York Dordrecht London (eBook) Library of Congress Control Number: 2014944745 © Springer-Verlag Berlin Heidelberg 2014 This work is subject to copyright All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed Exempted from this legal reservation are brief excerpts in connection with reviews or scholarly analysis or material supplied specifically for the purpose of being entered and executed on a computer system, for exclusive use by the purchaser of the work Duplication of this publication or parts thereof is permitted only under the provisions of the Copyright Law of the Publisher's location, in its current version, and permission for use must always be obtained from Springer Permissions for use may be obtained through RightsLink at the Copyright Clearance Center Violations are liable to prosecution under the respective Copyright Law The use of general descriptive names, registered names, trademarks, service marks, etc in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use While the advice and information in this book are believed to be true and accurate at the date of publication, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made The publisher makes no warranty, express or implied, with respect to the material contained herein Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com) Special thanks appertains to Dr M Morgan, Christchurch Hospital, NZ, for his inspiring suggestions and particularly his editorial support I would like to thank my wife Manuela for her understanding and support during the writing of this book Wolfgang Krüger Contents Mechanical Ventilation 1.1 Acute Respiratory Failure 1.2 Epidemiology 1.3 Ventilator Modes Nomenclature 1.4 Volume-Controlled (VC) Versus Pressure-Controlled (PC) Ventilation 1.5 Indications for Intubation and Mechanical Ventilation 1.6 Patient–Ventilator Interaction 1.7 Basics of Respiratory Physiology and Pathophysiological Issues 1.8 Pressures 1.9 Ventilator-Induced Lung Injury (VILI) 1.10 PEEP 1.11 Cardiovascular Effects of Positive Pressure Mechanical Ventilation (PPMV) 1.12 Conclusion for Overall Respirator Settings 1.13 Ventilation of Nonobstructive Acute Respiratory Failure Patients Not Suffering from ALI/ARDS 1.13.1 Summary, Invasive Mechanical Ventilation, Initial Settings in Non-ALI/ARDS Patients 1.13.2 Non-invasive Positive Pressure Ventilation (NIV) in Non-ALI/ARDS Patients 1.14 Mechanical Ventilation in COPD and Asthma 1.14.1 Respiratory Support in COPD Patients 1.14.2 Respiratory Support in Asthma Patients 1.15 Ventilator-Associated Pneumonia (VAP) 1.16 Weaning References 1 10 15 18 23 26 36 36 39 40 41 45 48 51 53 61 vii viii Contents Acute Respiratory Distress Syndrome (ARDS) 2.1 Definition 2.2 Epidemiology and Prognosis 2.3 Aetiology 2.4 Pathophysiology 2.5 Diagnosis and Clinical Features 2.6 Therapeutic Considerations 2.6.1 Respiratory Support/Mechanical Ventilation 2.6.2 Optimal PEEP 2.6.3 Permissive Hypercapnia 2.6.4 Treating Triggers 2.6.5 Respiratory Modes 2.6.6 Rescue Measures 2.6.7 Initial Ventilator Settings 2.6.8 Conservative (Restrictive) Fluid Management 2.6.9 Treatment of Acute Right Heart Dysfunction (RV-D)/Acute RV Failure (RV-F) (With the Focus on ARDS) 2.6.10 Extracorporeal Techniques 2.6.11 Miscellaneous References 99 99 102 103 104 110 113 113 114 117 118 119 120 123 124 Shock 3.1 Definition 3.2 Epidemiology 3.3 Aetiology 3.4 Pathophysiology 3.4.1 General Pathophysiological Aspects and Remarks 3.4.2 Compensatory Mechanisms and Shock Stages 3.5 Special Pathophysiology of 3.5.1 Cardiogenic Shock 3.5.2 Hypovolaemic Shock 3.5.3 Septic (Distributive–Vasodilative) Shock 3.6 Diagnostic and Clinical Issues 3.7 Management 3.7.1 General Approach 3.7.2 Vasopressor Application/Use 3.7.3 Cardiogenic Shock 3.7.4 Haemorrhagic Shock 3.7.5 Septic Shock References 159 159 159 160 163 163 170 173 173 179 181 191 197 197 206 210 215 217 226 125 129 129 129 Contents ix Sepsis 4.1 Epidemiology 4.2 Pathophysiology and Pathogenesis of Sepsis 4.3 Clinical and Diagnostic Issues 4.4 Management 4.4.1 Overview 4.4.2 Special Issues References 273 275 276 286 290 290 292 296 Acute Kidney Injury 5.1 Definition 5.2 Epidemiology 5.3 Aetiology 5.3.1 Pre-renal 5.3.2 Intrinsic, Intra-renal Causes 5.3.3 Postrenal Reasons 5.3.4 Doubts about Our Traditional Concept 5.4 Pathophysiology 5.5 Diagnostic Remarks 5.6 Management 5.6.1 Optimalization of Haemodynamics, Fluids and Vasopressive Agents 5.6.2 Loop Diuretics 5.6.3 Miscellaneous 5.6.4 Renal Replacement Therapy References 313 313 315 316 317 319 320 322 323 333 336 Nutrition in Critical Illness 6.1 Practical Aspects 6.1.1 Enteral Nutrition Versus Parenteral Nutrition 6.1.2 Timing of Initiation of Enteral Nutrition 6.1.3 Dosing of Enteral Nutrition 6.1.4 Protein Requirements 6.1.5 Special Formulas 6.1.6 Management of Aspiration Risk References 375 378 378 379 379 381 382 382 383 Appendix: Analgesia and Sedation in the Critically Ill Patients References 391 400 Index 409 337 343 344 345 349 References 407 146 Devlin JW, Roberts RJ, Fong JJ Efficacy and safety of quetiapine in critically ill patients with delirium: a prospective, multicenter, randomized, double-blind, placebo-controlled pilot study Crit Care Med 2010;38:419–27 147 Girard TD, Pandharipande PP, Carson SS, MIND Trail Investigators Feasibility, efficacy, and safety of antipsychotics for intensive care unit delirium: the MIND randomized, placebocontrolled trail Crit Care Med 2010;38:428–37 148 Pandharipande PP, Girard T, Sanders RD Comparison of sedation with dexmedetomidine versus lorazepam in septic ICU patients Crit Care 2008;12:P275 149 Dasta JF, Kane-Gill SL, Durtschi AJ Comparing dexmedetomidine prescribing patterns and safety in the naturalistic setting versus published data Ann Pharmacother 2004;38:1130–5 150 Inouye SK, Bogardus Jr ST, Charpentire PA A multicomponent intervention to prevent delirium in hospitalized older patients N Engl J Med 1999;340:669–76 151 Redeker NS Sleep in acute care settings: an integrative review J Nurs Scholarsh 2000;32:31–8 152 Li SY, Wang TJ, Vivienne WU SF Efficacy of controlling night-time noise and activities to improve patients’ sleep quality in a surgical intensive care unit J Clin Nurs 2011;20:396–407 153 Dennis CM, Lee R, Woodward EK Benefits of quiet time for neuro-intensive care patients J Neurosci Nurs 2010;42:217–24 154 Tamburri LM, DiBrienza R, Zozula R Nocturnal care interactions with patients in critical care units Am J Crit Care 2004;13:102–12, quiz 114 155 Cooper AB, Thornley KS, Young GB Sleep in critically ill patients requiring mechanical ventilation Chest 2000;117:809–18 156 Moore RD, Bone LR, Geller G Prevalence, detection, and treatment of alcoholism in hospitalized patients JAMA 1989;261:403–7 157 Bayard M, McIntyre J, Hill KR Alcohol withdrawal syndrome Am Fam Physician 2004;69:1443–50 158 Turner RC, Lichstein PR, Peden JG Alcohol withdrawal syndromes: a review of pathophysiology, clinical presentation, and treatment J Gen Intern Med 1989;4:432–44 Index A Abdominal compartment syndrome, 161 and acute kidney injury, 320 Abdominal hypertension, 161 and acute kidney injury, 320 ACE inhibitors, 330 Acidosis, buffers in septic shock, 224 ACTH, 170 Acute asthma attack heliox, 51 hydrocortisone, 50 magnesium, 50 Acute cor pulmonale (ACP), 111 incidence, 34 Acute exacerbations of COPD (AECOPD) infections of, 41–42 Acute kidney injury (AKI) in sepsis, 285 Acute kidney injury network (AKIN), 347 Acute lung injury (ALI), 99 Acute myocardial infarction (AMI), 162, 176 coronary endothelial dysfunction, 176 Acute respiratory distress syndrome (ARDS) acute cor pulmonale (ACP), 109, 116 alveolar epithelium, 106 antioxidants, 107 chest wall (thoracic) compliance, 108 circulatory shock, 109 conservative (restrictive) fluid management, 124–125 cumulative fluid balance, 124 pulmonary oedema, 124 criteria suggestive of, 99 endothelial dysfunction, 105 features of, 110 inflammation, 99 lung compliance, 108, 113 lung vascular permeability, 100 mechanical ventilation, 113 mechanisms provoking increased PVR endothelial dysfunction, 108 extrinsic vessel compression/occlusion, 109 hypoxic vasoconstriction, 108 increased vascular tone, 109 pulmonary vascular occlusion, 109 vascular remodeling, 109 neutrophils, role of, 106 PEEP, 114 proinflammatory mediators, 105 pulmonary hypertension, 108 pulmonary vascular resistance (PVR), 108 RV afterload, 109 RV contractile capability, 109 RV dilation, 109 RV dysfunction, 109 RV failure, 109 treatment of acute right heart dysfunction, 125–128 maintain perfusion pressure, 125 optimize RV preload, 125 reduce RV afterload, 125 strengthen RV systolic function, 125 treat underlying triggering factors, 125 vascular tone, 105 vasoconstrictive mediators, 105 vasodilating agents, 105 Acute respiratory failure definition of, hypercapnic respiratory failure, alveolar hypoventilation, causes of type II respiratory failure, COPD, asthama, W Krüger, A.J Ludman, Core Knowledge in Critical Care Medicine, DOI 10.1007/978-3-642-54971-7, © Springer-Verlag Berlin Heidelberg 2014 409 410 Acute respiratory failure (cont.) hypoxaemic respiratory failure, alveolar hypoventilation, causes of type I respiratory failure, pulmonary shunting, V/Q mismatch, perioperative ventilatory failure, respiratory failure in conditions of shock, ventilatory, hypercapnic respiratory failure, Acute tubular necrosis (ATN), 318, 322 ADH, 170 Adverse propofol effects, 395 AECOPD See Acute exacerbations of COPD (AECOPD) AECOPD/COPD antibiotic therapy, 48 bronchodilators, 47 hydrocortisone, 48 invasive PPMV indications for intubation, 47 NIV settings in, 46 extrinsic PEEP, 46 PEEPI, 46 prednisone, 48 Aetiologies of acute kidney injury, 316, 317 Afferent arteriole, 324 Afferent vascular tone, 327 Afterload mismatch in CS, 175 Aggressive early volume resuscitation, 290 Airway obstruction asthma, 23 COPD, 23 Airway pressure (PAW), 10, 16 components of airflow, 12 airway resistance, 12 respiratory system compliance, 12 tidal volume, 12 Airway pressure release ventilation (APRV), 119, 123 AKIN See Acute kidney injury network (AKIN) AKIN definition and classification of acute kidney injury, 314 Albumin, 340 Alcohol withdrawal and delirium, 400 ALI See Acute lung injury (ALI) ALI/ARDS, 108 Alveolar capillaries, extra/intra, 32 Alveolar damage, 19, 100 Alveolar fluid clearance, 106 Alveolar overdistenion/overinflation, 20 at alveolar–capillary interface, 20 Index Alveolar pressure (PAL), 10, 15 definition of, 16 Alveoles, 113 AMI See Acute myocardial infarction (AMI) Amount of calories, 379 Anaerobic metabolism, 164 Anaerobic tissue metabolism, 161 Analgesia, 392–394 Analgesia-first sedation principle, 392 Analgesic and sedative practice, 391 Anamnestic body weight, 380 Anaphylactic shock, 163 Angiotensin II, 326 Antibiotics in septic shock, 219 Anti-inflammatory cytokines, 279 Anti-inflammatory lipids, 382 Antimicrobial treatment, 290 Antithrombotic prophylaxis in sepsis, 295 Anxiety in critical illness, 391 APRV See Airway pressure release ventilation (APRV) ARDS aetiology direct lung injury, 103 extrapulmonary-induced ARDS, 103 multifactorial and heterogenous pathologies, 103 ARDS LPV initial ventilator settings, 123–124 ARDS mechanical ventilation permissive hypercapnia, 117–118 acidosis, 118 ARDS network, 37, 115 Arginine-supplemented formulas, 382 ARMA study, 26, 116 Arterial blood pressure, 206 Arterial hypotension and shock states, 192 Arterial hypoxaemia, 107 diffusion, 107 ventilation-perfusion mismatch, 107 Arterial tone, 202 Arteriolar–venular/venous (AV) shunting, 164 Arteriovenous or venovenous haemofiltration (CAVHF, CVVHF), 347–348 Aspiration risk, 382–283 Asthma, 162 β2-agonists, ipratropium, 50 auto-PEEP, 43 dynamic hyperinflation, 44 gas trapping, 44 indications for intubation in asthma patients, 49 Asynchronies asynchrony index (AI), 10 trigger asynchronies, Index Asynchronies (patient–ventilator interactions), Atelectasis, 113 Atelectatic, 35 Atelectrauma, 21 atelectasis, 20 ATLS protocol, 217 ATN See Acute tubular necrosis (ATN) ATP, 164 Atypical antipsychotics, 399 Autoregulated blood flow distribution in CS, 178 Autoregulation disrupted renal autoregulation, 330 in sepsis, 295 in septic shock, 187, 219 in shock, 192 Autoregulatory threshold, 208, 330, 342 Azotemia, 333 B Baby lung, 19, 113 Bacterial colonization, 375 Bacterial substrates, 166 Bacterial translocation, 375 Baro-and cardiopulmonary receptors, 172 Baroreceptors, 180 Barotrauma air leak, 19 interdependence of traction forces, 19 Behavioural Pain Scale (BPS), 392 Benzodiazepines, 399, 400 Benzodiazepines and sedation, 395 Berlin definition features of, 101 Bilateral infiltrates, 99, 110 Bi-fashioned relationship, 35 Biotrauma, 105 BiPAP See Biphasic positive pressure ventilation (BiPAP) Biphasic positive pressure ventilation (BiPAP), 119, 123 Blood cultures indication of, 288 Blood distribution within the kidneys, 325 Blood glucose control in septic shock, 223–224 Blood products in haemorrhage, 216 Blood transfusion-related ALI, 104 BPS See Behavioural Pain Scale (BPS) Breathing mechanism, 10 Buffer agents and renal/metabolic acidosis, 344 Buffering in CS, 215 BUN, 326 Burn injury and feeding, 382 Burns, 164 411 C CAM-ICU See Confusion assessment method for the ICU (CAM-ICU) Capillary leak (syndrome), 168 Capillary leakage, 161, 166 Capillary leakiness in sepsis, 278 Capillary refill, 193 Cardiac output, 192 Cardiac output (CO) in CS, 175 Cardiogenic pre-shock, 178, 193 Cardiogenic shock (CS), 160 clinical characteristics of, 173 definition of, 173 haemodynamic characteristics of, 174 loss of myocardial contractility, 174 Cardiovascular abnormalities associated in sepsis altered microhaemodynamics, 283 hypo-responsiveness, 283 hypovolaemia, 283 myocardial depression, 283 peripheral vasodilation, 283 CARS See Compensatory anti-inflammatory response syndrome (CARS) Catabolic metabolism, 375 Catecholamines, 170 Causes for increased RV outflow impedance, 32 Causing high abdominal pressures, 321 Cellular and tissue dysoxia/hypoxia, 164 Cellular hypoxia/ischaemia, 159 Cellular metabolic requirements, 159 Cellular /mitochondrial collapse, 170 Central venous (ScvO2) and mixed venous (SvO2) oxygen saturation in shock states, 194 Central venous catheters (CVC ) infection antibiotic treatment, 294 common pathogens, 294 Central venous pressure (CVP) and fluid management, 339 and fluid responsiveness, 291 and renal function, 321 Central venous pressure /pulmonary occlusion pressure (CVP/PCWP), 201 Chest wall compliance, 12 Chest x-ray, 110 CIN See Contrast-induced nephropathy (CIN) Classical paradigm of CS mechanical problem, 175 Clinical ARDS features, 107 Clinical features suggestive for tissue hypoperfusion, 191 412 Clinical sepsis syndrome determined by cytokines local cytokines, 279 systemic cytokines, 279 Clinical signs and symptoms in sepsis, 286 CO/CI, 201 CO (SV × HR) is a major determinant of oxygen supply, 198 Collapse, 114 Colloids, 340 Common final shock pathway, 161 Compensated shock, 173 Compensatory anti-inflammatory response syndrome (CARS), 279, 280 Compliance curves, 13 Compliance of respiratory system, 27 compliance of chest wall (CW), 12 compliance of lungs (CL), 12 definition of, 12 Confusion assessment method, 398 Confusion assessment method for the ICU (CAM-ICU), 398 The continuum of prerenal azotemia and acute tubular necrosis, 319 Contrast-induced nephropathy (CIN), 344–345 COPD/AECOPD airway resistance, 42 dynamic hyperinflation, 42 FRC, 42 loss of lung recoil, 42 trapped air, 42 Coronary perfusion in CS, 176 Corticosteroids, 170 CORTICUS study, 221 CPAP in CS, 214 CPOT See Critical Care Pain Observation Tool (CPOT) C-reactive protein (CRP), 288 Createnine insensitive and non-specific, 333 Creatinine serum levels, 333 Critical Care Pain Observation Tool (CPOT), 392 Cross-linked pathways in sepsis defence, 286 Crosstalk elements of innate immunity, 277 of endothelial cells, 167 of the enteriric and central nervous system, 166 and haemodynamics, 167 CRP See C-reactive protein (CRP) Cryptic, pre-shock, 192 Cryptic (subclinical) shock in hae,orrhage, 179 Index Crystalloids, 340 Crystalloids, colloids and albumin, 205 CS See Cardiogenic shock (CS) Current / new cardiogenic shock paradigm, 177 CVP and fluid loading, 202 CVP/PCWP See Central venous pressure / pulmonary occlusion pressure (CVP/PCWP) Cyanosis, 193 Cyclic alveolar recruitment, 114 Cytokines, 105, 176, 273 Cytokines and metabolism, 376 Cytopathic hypoxia, 173, 182 Cytopathic shock, 159 D Daily interruptions of sedation, 395 Dead space ventilation, 108 Decelerating flow pattern, 123 Decelerating flow wave pattern, 119 Decompensated shock, 173 Decreased venous tone, 162 Defects in cellular oxygen utilization in septic shock, 182 Defence mechanisms, 285 Definition of circulatory shock, 159 Delirium, 397–400 Depletion of ATP in acute kidney injury, 328 Derecruitment, 30 Dexmedetomidine (DMDT), 395, 399 Diagnosis of delirium, 397, 398 Diastolic and systolic dysfunctions in CS, 174 Diastolic ventricular interaction (DVI), 28, 34, 109, 339 pericardium, 29 Discomfort, 391 Diseased lungs in healthy lungs, 31 during PPMV, 31 Disproportionately distributed blood flows, 159 Dissociation between macro-and microcirculation, 200 Dissociation between macro-and microcirculatory response to volume loading, 199 Dissociation between micro-and macrocirculation, 169 Dissociation/link between macro-and microcirculation, 192 Distributive/vasodilatatory shock, 160 DMDT See Dexmedetomidine (DMDT) Dob See Dobutamine (Dob) Dob in CS, 213 Index 413 Dob in septic shock, 220, 222 Dobutamine (Dob), 210 and microcirculation, 291 in septic shock, 225 Dopamine, 344 Dosing of renal replacement therapy (RRT), 348 Drug reduction and delirium, 400 Drugs and autoregulation, 317 Drug tolerance in opioid analgetics, 394 During PPMV, 31 in diseased lungs, 31 in healthy lungs, 31 Dynamic hyperinflation trapped air, 23 Dynamic parameters of intravascular volume, 203 Dyssynchrony, 40 Established acute kidney injury, 332 EVLW See Extravascular lung water (EVLW) EVLWI See Extravascular lung water index (EVLWI) Evolution and pathobiology of ischaemic acute kidney injury, 328 Exposure of kidneys to hypoxia/ischaemia, 327 renal tissue to hypoxia/ischaemia, 330 Extrapulmonary ALI/ARDS and lung/chest wall compliance, 14 Extrapulmonary-induced ARDS sepsis, 104 Extravascular lung water (EVLW), 101, 111 pathological values, 112 Extravascular lung water index (EVLWI), 204 E Early goal-directed therapy (EGDT), 222–223, 291 Early invasive revascularization, 212 Echocardiography, 111 Effective circulating volume, 318 Efferent arterioles, 324 Efferent vessel, 324 EGDT See Early goal-directed therapy (EGDT) Elastance of respiratory system definition of, 12 Empiric antimicrobial drug choice, 293 EN See Enteral nutrition (EN) Endothelial activation, 105 Endothelial activation and dysfunction in acute kidney injury, 328 Endothelial cell activation and dysfunction in sepsis, 278 and dysfunction in shock states, 167 Endothelial cells, 277 Endothelial dysfunction and activation, 331 Endothelial dysfunction and vasomotor tone, 168 Endothelial dysfunction in pathobiology of acute kidney injury, 319 Endothelium, 167, 286 in sepsis, 277 in shock states, 167 Energy deficit, 375 Enteral feeding, 376, 377 Enteral Feeding Protocol, 283 Enteral nutrition (EN), 378 EPaNIC trial, 377 Epithelial cell, 106 F Failure of vascular smooth muscle constriction in sepsis, 183 Feeding, 375 Feeding of critically ill patients, 376 FENa, 334 Fentanyl, 391 FEUREA, 334 Fibrosing alveolitis, 107 FiO2, 123 FiO2/PaO2, 111 FiO2-PEEP tables, 115 Fluid administration, 337 Fluid administration in shock states, 198 fluid application, 206 resuscitate both macro-and microhaemodynamics, 198 timing of, 200 volume loading, 207 Fluid application in CS, 212 Fluid balance in acute kidney injury, 337 Fluid balances, 341 Fluid challenges, 198, 339 Fluid loading and microcirculation, 199 Fluid overload, 338, 341 Fluid overload in shock states, 198 Fluid responsiveness, 202, 339 Fluids in acute kidney injury, 337 Fluids in sepsis, 290 Fluid therapy in septic shock, 219 Fraction of arterial oxygen tension to inspired oxygen content, 99 FRC See Functional residual capacity (FRC) Functional acute kidney injury, 327 Functional residual capacity (FRC), 12, 117 414 G Gastric intolerance, 377 Gastric motility, 378 Gastric route, 379 Gastrointestinal barrier function, 375 blood and fluid losses, 161 tract and capnometry, 196 Gastroparesis, 375 Gas volume distribution in diseased lungs, 31 in healthy lungs, 31 during PPMV, 31 Genitourinary infection antibiotic treatment, 294 common pathogens, 294 GFR See Glomerular filtration rate (GFR) Glomerular capillary filtration pressure and renal perfusion/renal blood flow, 323 Glomerular filtration rate (GFR), 313, 323, 333, 334 Glomerulonephritis, 320 Glycaemic control, 375 Glycaemic control in sepsis, 295 Gram-positive exotoxic shock, 163 GTN in CS, 215 GTN in septic shock, 225 Gut elements in shock, 165 Gut hypoperfusion in shock states, 165 Gut motility, 375 H Haemodynamically relevant PEEP effects development of hypotension and hypoperfusion, 25 impairs hepato-splanchnic perfusion, 25 impairs renal perfusion, 25 increases in intrathoracic (pleural) pressure, 25 increases pulmonary vascular resistance, 25 increases RV outflow impedance, 25 RVafterload, 25 Haemodynamic profile of NA and Dob, 210 Haemorrhage, 215 Haemorrhagic, 161 Haemorrhagic shock, 179 Hallmarks of sepsis altered microhaemodynamics, 281 maldistributed and heterogenous blood flows, 281 mitochondrial dysfunction, 281 Index Hallmarks of shock states heterogeneity of microcirculatory blood flows in shock states, 169 maldistribution of blood flow, 164 systemic hypoperfusion and, 164 Hallucinations, 397 Haloperidol, 399 Harris–Benedict (H–B) equation, 380 Heart–lung interactions, 26, 35, 203, 340 Height of CVP, 203 Hemodialysis CAVHD, 348 Hemodialysis CVVHD, 348 Hepatobiliary infection antibiotic treatment, 294 common pathogens, 294 Heterogeneity of blood flows, 195 HFV See High-frequency ventilation (HFV) Hibernating myocardium, 174 High-frequency ventilation (HFV), 121 cyclic recruitment/de-recruitment, 121 High VT in PPMV, 21 Hormonal, neural and autoregulatory effects, 325 Host, 285 Host-related properties in sepsis, 282 Host’s reaction to pathogens / properties of pathogens, 280 Hydration is/fluids prior to radiocontrast, 345 Hydrocortisone in septic shock, 221 Hydrostatic pulmonary oedema, 100 Hyperactive delirium, 397 Hyperdynamic phase, 284 Hypergylcaemia, 377 Hyper-inflammatory response, 280 Hyperkalaemia in acute kidney injury, 344 Hypermetabolism, 375 Hypoactive delirium, 397 Hypoperfusion, 173, 331 Hyporeactivity of small vessels to catecholamines in sepsis, 183 Hypo-responsiveness, 284 Hypotension, 173 and CS, 178 in sepsis, 285 Hypotensive resuscitation, 216 Hypothalamic–pituitary–adrenal axis, 280 Hypovolaemia, 283, 316 Hypovolaemic shock, 179 stages of, 179 Hypovolemic shock, 160 blood tank disorder, 180 and MOF/MODS, 181 Hypoxia/ischaemia, 166, 331 Hypoxic cellular injury, 164 415 Index Hypoxic/ischaemic, 327 Hypoxic/ischaemic lesion, 164 Hypoxic pulmonary vasoconstriction, 30 Hypoxic respiratory failure, 99 Hypoxic vasoconstriction (Euler–Liljestrand reflex), 28 I I:E ratio, 123 IHD See Intermittent haemodialysis (IHD) Immunosuppression, 377 Immunosuppressive states, 282 Impacts of systemic inflammation on different vessel beds, 284 Impaired renal function, 333 Inadequate tissue supply with oxygen, 159 Inappropriate vasoconstriction, 176 Inappropriate vasodilation in CS, 176 Incidence of sepsis, 275 Incomplete shock, 172 Increased thoracic pressure, 162 Indications for PPMV, 7–8 Indications to initiate renal replacement therapy (RRT) by Bellomo and Ronco (2001), 346 by Lameire (2005), 346 Indirect calorimetry, 379 Inflammation, 166, 278, 323 Inflammatory mediators, 176 and PPMV, 21 and pulmonary threats, 37 regional distribution of inflammation, 22 Inflammatory process in CS, 176 Inflammatory process in sepsis self-sustaining, 282 Inflammatory response, 105, 331 Initial settings in Non-ALI/ARDS patients, 39–40 Initiation of enteral feeding, 379 Innate immune response, 167, 273 Innate immune response to cellular and tissue injury, 166 Innate immune system, 276 Inotropes in sepsis, 291 Inotropic support in septic shock, 220–221 Intact nephrons, ATN and renal dysfunction, 322 Intentional underfeeding, 378 Intermittent haemodialysis (IHD), 348 Interstitial nephropathy, 320 Interventricular septum, 178 Intestine ‘motor’of critical illness, 165 Intra-abdominal hypertension, 316, 341 Intraabdominal pressure and chest wall elastance, 13 Intra-aortic balloon counterpulsation (IABP) in CS, 214 Intracellular metabolism and vascular tone/ blood flow 198 link between, 185 Intraglomerular haemodynamics, 327 (Intra-)renal microcirculation, 327 Intra-renal or intrinsic renal, 317 Intra-renal vasoconstriction, 318 Intrathoracic pressure definition of, 16 Intrinsic, intra-renal, 319 Invasive mechanical ventilation, 39–40 Invasive mechanical ventilation in acute asthma attack initial ventilator settings, 49–50 permissive hypercapnia, 50 Invasive positive pressure ventilation in AECOPD initial ventilator settings, 47 Invasive PPMV in AECOPD/COPD indications for intubation, 47 I–R injuries, 165 I–R injury in hypovolemic shock, 179 Irreversible shock, 173 failure of microcirculatory system as a conditio sine qua non, 170 Ischaemia in CS, 174 Ischaemic acute kidney injury, 320, 327 J Just bacterial infection and sepsis, 182 L Lactate in shock states, 194 Lactate levels in shock states, 192 Lactic acid in sepsis, 288 Lean body mass, 375 Lean-or normal-weight, 380 Left ventricular filling pressure (LVEDP) in CS, 175, 178 and LV compliance, 178 and preload, 178 Levosimendan in septic shock, 221 LIP See Lower inflection point (LIP) Loading conditions in CS, 174 Local inflammation (LIR), 166 Local inflammatory response, 276 Local, intra-renal hemodynamic, 325 416 Local tissue carbon dioxide tension, 196 Loop diuretics, 330, 343 Lorazepam, 395 Low cardiac output, 316 Lower GI tract infection antibiotic treatment, 294 common pathogens, 294 Lower inflection point (LIP), 115 Low-pressure receptors, 180 LPV See Lung protective ventilation (LPV) Lung de-recruitment, 114 Lung protective strategy, 40 Lung protective ventilation (LPV), 36, 114, 123 definition of, 36 plateau pressure, 114 plateau pressure limit, 116 tidal volume, 114 Lung recruitment, 114 Lung volume, 34, 35 LV afterload, 27 LV assist devices in CS, 214 LV dysfunction, 176 LVEDP definition of, 29 LV–EF, 27 LVEF in CS, 174 LV–SV, 27 M Macrocirculation in hypovolemic shock, 179 Macrocirculation in sepsis, 187 Macrocirculatory surrogates of volume loading, 200 Macrohaemodynamic parameters, 338 Magnitude of PPLAT, 17 Maintenance fluids, 341 Major surgery, 316 Maldistribution, 161 Maldistribution in septic shock, 182 Malnutrition, 375 Manifest intrinsic acute kidney injury, 327 Mean arterial pressure (MAP) and arterial tone, 202 in CS, 175, 212, 213 in haemorrhage, 216 height, 208 represents organ perfusion pressure, 207 in sepsis, 285, 295 in septic shock, 184, 219 Mean cumulative fluid balance, 201 Mechanical positive pressure ventilation, 340 Mechanical ventilation, 161, 162 Index Mechanical ventilation in patients not suffering from ALI/ARDS, 38 Mechanical ventilatory support effects of, Mechanisms of multiorgan dysfunction in sepsis, 282 Medulla, 325 Medullary hypoxia/ischaemia, 325 Membrane oxygenation, 129 Mental status and hypoperfusion / in shock states, 193 Metabolic stress, 375 Metabolic waste products, 313 Microbial infection, 273 Microbial-related issues in sepsis, 282 Microcirculation, 161, 195 in CS, 179 in hypovolemic shock, 181 in sepsis microcirculation as the motor of sepsis, 186 in shock states, 167 and substrate exchange, 168 Microcirculatory and mitochondrial distress syndrome (MMDS), 187 Microcirculatory monitoring available in septic shock, 220 sublingual capnometry, 220 Microhaemodynamics in CS, 211 and Dob in septic shock, 225 in sepsis, 278 Microvascular alterations, 20 Microvascular cell sequestration, 106 Midazolam, 395 Mitochondria, 159 Mitochondrial dysfunction hallmark of sepsis, 286 MMDS See Microcirculatory and mitochondrial distress syndrome (MMDS) Modalities of renal replacement therapy (RRT), 347 MODS See Multiorgan dysfunction (MODS) MODS/MOF, 105, 166 MOF/MODS and sepsis, 182 Morphine, 391 Multiorgan dysfunction (MODS), 279, 286 second hit, 22 Myocardial compliance, 178 Myocardial depression, 283 Myocardial depression in sepsis, 188 depressed intrinsic contractility, 188 Myocardial reserve capacity, 202 Myogenic response of renal vasculature, 324 Myopathic reasons of shock, 162 417 Index N N-acetylcysteine (NAC) in contrast-induced acute kidney injury, 345 Near infrared spectroscopy (NIRS), 196 Nephrotoxic agents/drugs, 316 Nephrotoxic insults and manifest (intrinsic) acute kidney injury, 327 Neuroendocrine system, 280 Neurologic shock, 163 Neuromuscular blocking, 397 Neuropathic pain, 394 Neutrophil gelatinase-associated lipocalin (NGAL), 335 NGAL See Neutrophil gelatinase-associated lipocalin (NGAL) NIRS See Near infrared spectroscopy (NIRS) Nitric oxide, 176 in sepsis, 184 system, 168 NIV in asthma, initial settings, 48–49 Non-invasive positive pressure ventilation (NIV) non-ALI/ARDS patients, 40–41 Non-invasive PPMV in Non-ALI/ARDS patients initial respirator settings, 41 Non-invasive ventilation (NIV) in COPD, 45–46 Noradrenaline (NA), 209 in CS, 213 Norepinephrine, 343 Normotensive blood pressure and acute kidney injury, 335 Nosocomial pneumonia antibiotic treatment, 294 common pathogens, 294 NOS system /NO in septic shock, 184, 188 NO synthase in CS, 176 NSAIDs, 330 NSAIDs and ACE inhibitors, 317 Nutrition and survival in critical illness, 375 O Obstructive shock, 160 Oesophageal pressures (PES), 16 Oliguria, 334 Oliguria/anuria, 333 “Open lung concept”, 30 Opioid analgetics and their dosing, 394 Opioids, 393 OPS See Orthogonal polarization spectral (OPS) Organ failure in sepsis, 278 Organ hypoperfusion in sepsis, 287 Orthogonal polarization spectral (OPS), 196 OSCAR trial, 122 OSCILLATE trial, 122 Outer medullary hypoxia, 327 Overfeeding, 375 Overinflation, 20 Oxygen debt, 159, 164 Oxygen deprivation, 164 P Pain awareness and treatment, 392 Pain in critical illness, 391 PaO2/FiO2, 99 Parasympathetic tone, 170 Parenteral nutrition (PN), 378 Passive leg raising (PLR) and fluid administration, 204 Pathogen-associated molecular patterns, 277 Pathogenesis of CS, 177 Pattern recognition receptors, 277 PBW See Predicted body weight (PBW) PCT See Procalcitonin (PCT) PCV See Pressure-controlled ventilation (PCV) PCWP, 99 Peak airway pressure (PPEAK), 15, 43 Perfusion of organs determinantes of, 341 Pericardium, 109 Peripheral resistance (SVR / SVRI) in CS, 177 Peripheral resistance in sepsis, 184 Peripheral vasodilation, 284 Permeability, 99 Permeability-induced pulmonary oedema, 100 Permeability of pulmonary vasculature, 104 Permissive resuscitation, 216 Physiological human inhalations, 37 Plateau pressure (PPLAT), 35, 36, 42, 43, 111, 123 definition of, 15 gas trapping, 43 relationship to lung compliance lung compliance, 42 value of, 17 PN See Parenteral nutrition (PN) Points of no return (NRP), 173 Positive end-expiratory pressure (PEEP), 21, 30, 35, 36, 111, 123, 161 ACP, 33 auto-PEEP (PEEPi), 23 418 Positive end-expiratory pressure (PEEP) (cont.) beneficial PEEP effects attenuates pulmonary shunting, 24 attenuates release of inflammatroy mediators, 24 chest wall stiffness, 24 increase in FRC, 23 increase in lung compliance, 23 redistributes fluids, 24 reduces work of breathing, 24 stabilizes lung units, 24 dead space, 24 diastolic ventricular interaction (DVI), 25 increase interstitial fluid, 24 in ITP, 33 intrathoracic blood volume, 30 ITP, 30 PEEPe, 23 pulmonary blood flow, 30 recruiting collapsed lung tissue, 31 relative contraindications, 24 RV afterload, 30 Positive pressure mechanical ventilation (PPMV), 26, 34 ACP, 25, 32–34 APRV, BiPAP, considerable respiratory muscle dysfunction and atrophy, continous positive airway pressure (CPAP), cyclic collapse, 21 diastolic ventricular interaction (DVI), 25 dynamic hyperinflation, 23 epidemiologic indications, increase in ITP, 33 inspiratory flow, 22 inspiratory flow patterns, intrathoracic blood volume in PPMV, 27 intrathoracic pressure (ITP), 26 inversed ratio ventilation (IVR), LVafterload, 31 LVEDP, 29 mechanical strain, 21 mechanical ventilatory support, PEEP, 21–22, 33 pressure controlled ventilation (PC(V)), pulmonary blood flow in PPMV, 27 pulmonary vascular resistance (PVR), 28 relationship of transpulmonary pressure and RV afterload, 28 reopening of atelectatic areas, 21 RV cavity size, 29 Index RV dilation, 29 RV dysfunction, 28 RVEDP, 29 RV filling, 26 RV output impedance, 27 RV preload, 26 shear stress, 21 systemic inflammatory response (SIR), 22 tidal volume, volume controlled ventilation (VC(V)), Post-pyloric feeding route, 283 Post-pyloric routes, 379 Postrenal, 317 Postrenal acute kidney injury, 320 Posttrauma, 164 Potassium ATP (KATP) channel, 185 PPV See Pulse pressure variation (PPV) Predicted body weight (PBW), 36 Predominant aetiology is LV failure, 174 Preglomerular resistance, 326 Prerenal, 317 Pre-renal acute renal failure, 331 Prerenal azotemia, 317, 326 definition of, 318 Pressure-controlled ventilation (PCV), 119, 123 Pressure support (PS), 4–5 Pressure support ventilation (PSV), 4–5 Pressure-volume curve, 115 Procalcitonin (PCT), 288 Program to improve care in acute renal disease (PICARD) experience, 346 Program to improve care in acute renal disease (PICARD) study, 338 Proinflammatory cytokines, 166, 277 Proinflammatory cytokines enter the systemic circulation and systemic circulation, 285 Proinflammatory mediators, 110, 165 Pro-kinetic drugs, 283 Pro-kinetic effect, 378 Propofol, 395 Protein catabolism, 375 Protein requirements, 381 Proteolysis, 376 PS See Pressure support (PS) PSV See Pressure support ventilation (PSV) Pulmonary ARDS and lung/chest wall compliance, 14 Pulmonary (lung) compliance, 12 Pulmonary edema, 104, 110 Pulmonary elastic properties, 16 Pulmonary embolism, 162 Pulmonary endothelium, 104 Index Pulmonary hypertension, 162 Pulmonary infiltrates and ARDS, 99 Pulmonary oedema alveolar flooding, 19 interstitial oedema, 19 in mechanical ventilation, 19 Pulmonary oedema and CS, 178 Pulmonary vascular permeability index (PVPI), 101, 111 negative predictive value of, 102 values, 112 Pulmonary vascular resistance (PVR), 32–34, 35 acute cor pulmonale (ACP), 32 extra-alveolar vessels, 28 intra-alveolar capillaries, 28 Pulse pressure variation (PPV), 203 PVPI See Pulmonary vascular permeability index (PVPI) PVR See Pulmonary vascular resistance (PVR) R RAAS See Renin–angiotensin–aldosterone system (RAAS) Radiocontrast, 317 RASS See Richmond Agitation and Sedation Scale (RASS) RBC transfusions in septic shock, 222 RBF See Renal blood flow (RBF) Reaction of vascular tissues, 166 Reasons for failure of SBT abdominal distension, 57, 59 acute myocardial ischaemia, 57 critical illness myopathy, 57 hyperinflation (COPD), 57 LV heart failure, 57, 58 muscle fatigue, 57 obesity, 57, 59 respiratory muscles, 57 secretions encrustation, 57 sepsis, 57 Recruiting collapsed lung tissue FCR, enlarging and shifting, 31 reducing PVR, 31 Recruitment manoeuvres, 21, 120 Red blood cell transfusion in sepsis, 291 Redistribution in hypovolemic shock, 181 Red microhaemodynamics, 283 Regional microcirculatory, 331 Regional perfusion, 326 Relationship PVR and lung volume bimodal fashion, 28 419 Relative vasopressin deficiency, 183, 186 Remifentanil, 393 Renal autoregulation, 324 Renal autoregulatory mechanisms, 326 Renal autoregulatory threshold in mammalians, 342 in sepsis, 295 Renal autoregulatory threshold/MAP, 342 Renal blood flow (RBF), 323 Renal endothelial cells, 328 Renal fluid/blood losses, 161 Renal haemodynamics in sepsis, 323 Renal hypoperfusion, 317, 319, 323 Renal hypoperfusion and nephrotoxic drugs, 319 Renal ischemia and tubular abnormalities, 320 Renal medulla outer medulla, 325 Renal pathophysiology, multifactorial, 323 Renal perfusion, 342 Renal replacement therapy (RRT), 345 Renal vascular tone, 328 Renin–angiotensin–aldosterone system (RAAS), 170 Renin–angiotensin (aldosterone) systems, 174 Renoprotective measures, 344–345 Reperfusion, 164 Reperfusion in acute kidney injury, 329 Replenishing hypovolaemia, 341 Residential immune cells, 276 Resistance to airflow, 27 Resistance vessels, 166, 183 Respiratory quotient (RQ), 379 Respiratory rate, 123 Restrictive fluid management, 200 rhAPC, 222 RICACOS trial, 377 Richmond Agitation and Sedation Scale (RASS), 396 RIFLE criteria, 313 RIFLE criteria and RRT initiation, 347 Right-sided heart failure and intraabdominal venous pressure, 322 Risk factors of delirium, 398 Routine intensive care procedures and stress/ pain, 392 RQ See Respiratory quotient (RQ) RV afterload, 28, 32, 34 right ventricular ischaemia, 33 RV dilation, 33 RVEDP See RV end-diastolic pressure (RVEDP) RVEDV, 30 420 RV elastance and pulmonary arterial elasrance, 109 RV end-diastolic pressure (RVEDP), 109 RV function, 111 RV ischaemia, 110 RV outflow impedance, 34, 116 S SCre See Serum creatinine level (SCre) ScvO2 in sepsis, 291 SDF See Sidestream dark-field (SDF) Second hit in hypovolemic shock, 179 Second hits, 165, 282, 286 Sedation, 394–397 Sedation scores, 391 Sepsis, 161, 162, 316 definition of, 273 diagnosis/suspicion of infection, 274 2003 sepsis definition, 274 Septic cardiomyopathy haemodynamic profiles in sepsis, 189 Septic myocardial depression, 162 Septic shock altered microcirculation as a hallmark, 182 definition of, 181, 275 endothelial cell injury, 182 haemodynamic profile of, 182 incomplete shock, 163 Serum creatinine level (SCre), 313 Severe acidosis in acute kidney injury, 344 Severe acute asthma attack airway obstruction, 43 airway obstruction, reversible, 43 auto-PEEP, 43 bronchomotor tone, 43 central airways, 43 hyperinflation, 43 outward recoil of the chest wall, 43 Severe asthma attack, 43 Severe community-acquired pneumonia (CAP) infection antibiotic treatment, 294 common pathogens, 294 Severe sepsis definition of, 275 Shock index, 194 Shock states microcirculation, 168 SHOCK trial, 174 Shock types, 160 Shunting, 169, 182 Sidestream dark-field (SDF) technique, 196, 207 Signs of hypoperfusion, 287 Index Signs of organ and tissue hypoperfusion, 338 SIMV See Synchronized intermittent mandatory ventilation (SIMV) SIR See Systemic inflammatory response (SIR) SIRS See Systemic inflammatory response syndrome (SIRS) SPV See Systolic pressure variation (SPV) SSC See Surviving sepsis campaign (SSC) Stress in critical illness, 391 hormones, 166 response in sepsis, 278 Stunning myocardium, 174 Sublingual pCO2 capnometry, 196 Supplemental parenteral feeding, 377 Surrounding pressure (PSUR), 15 Surviving sepsis campaign (SSC), 217, 276 SV in CS, 175 Sympathetic and neurohumoral compensation, 171 Sympathetic discharge, 170 Sympathetic escape, 173 Sympatheticoadrenal and hypothalamic– adrenal system, 170 Sympathetic system, 174 Synchronized intermittent mandatory ventilation (SIMV), The syndrome of acute kidney injury as defined by RIFLE criteria, 315 Systemic hypoperfusion, 159 Systemic hypotension and acute kidney injury, 323 Systemic inflammation, 110 Systemic inflammation in the pathobiology of acute kidney injury, 319 Systemic inflammatory response (SIR), 162, 164 in cardiogenic shock, 176 Systemic inflammatory response syndrome (SIRS), 166, 176, 273, 279, 285 characteristics of, 181 effect on host, 285 MODS, 22 of nonseptic, toxic genesis, 166 Systemic vasoconstriction in CS, 175 Systolic blood pressure, 173 Systolic pressure variation (SPV), 203 T TAPSE See Tricuspid annular plane systolic excursion (TAPSE) TGF See Tubuloglomerular feedback (TGF) Index Thromboembolism prophylaxis in CS, 215 in septic shock, 223 Tidal volume, 34, 36 Timing of renal replacement, 346 Tissue dysoxia, 194 Tissue hyperpermeability secondary in septic shock, 183 Tissue hypoperfusion, 273 Tissue hypoxia/dysoxia, 195 To catecholamines, 284 Tones of afferent and efferent arteriole, 324 Transpulmonary pressure (PTRANS), 34 alveolar distending forces, 12 definition of, 10, 15 values of, 17 Trauma, 161 Treatment of acute right heart dysfunction maintain perfusion pressure norepinephrine, 128 optimize RV preload hypo-and hypervolaemia, 126 reduce RV afterload ACP, 126 hypoxic vasoconstriction, 126 inhaled NO, 127 RV afterload, 126 strengthen RV systolic function dobutamine, 127 levosimendan, 127 phosphodiesterase inhibitors, 127 treat underlying triggering factors LPV, 125 Tricuspid annular plane systolic excursion (TAPSE), 111 True hypovolaemia, 318 Tubular back-leak, 329 Tubuloglomerular feedback (TGF) fine-tune, 324 Type of fluid in volume replenishment, 205 U Upper inflection point, 115 Urea concentrations and RRT initiation, 347 Urinary biochemistry, 334 unable to differentiate pre-renal from manifest acute kidney injury, 335 Urinary indices, 322 Urinary output (uo), 313, 333 determinantes of, 334 Utilization of nutrients in critical illness, 376 421 V Valvular heart disease, 162 Variation of SVV, 203 Vas afferent, 324 Vascular congestion of the outer medulla, 329 Vascular resistance, 171 Vascular response, 278 Vascular tone and endothelium, 167 loss of regulation of, 169 and vasoactive agents, 167 Vascular tone in sepsis, 184, 278, 290 Vasculitis, 320 Vasoconstriction in shock, 166 Vasoconstrictive agents, 167 Vasodilation in shock, 166 Vasodilative mediators, 167 Vasomotor paralysis, 173 Vasomotor tone, 171 in septic shock, 183 vasoplegia, 172 Vasopressin, 225 Vasopressor agents in acute kidney injury, 337 Vasopressor application in shock states, 209 Vasopressors autoregulation, 207 indications of, 206 and MAP, 206 in sepsis, 295 in septic shock, 219 Venous congestion, 316 Ventilator-associated pneumonia (VAP), 51–53 colonization, 51 cuff pressure, 52 endotracheal tube (ETT), 51 enteral feeding, 52 ETT cuff, 51 head-up positioning, 52 oropharynx, 51 sedation interruption, 52 stomach, 51 suctioning, 51 Ventilator-induced injury (VILI) atelectrauma, 18, 20 barotrauma, 18, 19 biotrauma, 18, 21 volutrauma, 18 Ventilator modes, 4–5 Ventricular interaction, 178 Ventriculo-pulmonary coupling, 33 RV dysfunction, 33 RV failure, 33 422 Volumecontrolled ventilation (VCV), 119, 123 Volume depletion, 340 Volume overload, 201 Volume replenishment in sepsis, 295 Volume status in acute kidney injury, 337 VPI See pulmonary vascular permeability index (PVPI) VT, 119, 123 W Weaning definition of, 53 reduction of respiratory support, 53 Index Weaning from mechanical ventilation, 53 daily interruption of sedation, 53 failure of SBT, 55 patients who failed SBT, 59–61 ventilator settings, 60 PEEP, 54 PSV, 54 rapid shallow breathing index, 55 reasons for failure of SBT, 56–57 screening criteria to wean a patient, 54 SIMV, 54 Spontaneous Breathing Trial, 55 T-piece, 54 [...]... triggering, untriggered breaths or trigger asynchrony, may occur as well during inspiration, indicated by an abrupt increase in inspiratory flow (in PC mode) or transient abrupt decrease in airway pressure (VC mode) [89, 95] Dynamic hyperinflation, limited respiratory drive, weakness of respiratory muscles and insensitive trigger settings are causally underlying ineffective efforts [102] Since resolving... overall situation: Increases in intrathoracic (pleural) pressure may impede venous return and hence cardiac filling [328, 361], potentially provoking a fall in CO, but diluted venous return is not the only mechanism involved in the possible reduction in CO Increases pulmonary vascular resistance [362] and decreases pulmonary blood flow [363] due to the increase in lung inflation following the increased alveolar... example [11]), hypoxaemia due to shunting will persist even if oxygen is supplied [11, 15] Pulmonary shunting can be interpreted as an extreme form of V/Q mismatch [15] which occurs in the W Krüger, A.J Ludman, Core Knowledge in Critical Care Medicine, DOI 10.1007/978-3-642-54971-7_1, © Springer-Verlag Berlin Heidelberg 2014 1 1  Mechanical Ventilation 2 s­ etting of alveolar hypoventilation or alveolar... applying pressure negative or positive, to the airways [40], is associated with a couple of potentially adverse effects termed ventilator-induced lung injury, VILI [188, 214] Due to the complexity of the interaction between externally applied inflation and the body, we are still facing significant problems understanding it in principle [137, 215], but particularly facing difficulties in managing individual... more coexisting or consecutively occurring insults, one being mechanical ventilation and the other the need for mechanical ventilation sensitizing the lungs (the initial injury), a second hit hypothesis initiating MODS [213, 299] Inspiratory flow may also have an impact on VILI development as most recent literature suggests High inspiratory flow is believed to reinforce transmission of kinetic energy... factors depicted above including enhanced FRC resulting from recruitment of collapsed alveoli [334, 350] and mitigation of alveolar oedema [351], reduction in shunting [217], stabilizing of damaged alveoli [217], by modifications in surfactant [352] and alterations in alveolar microhaemodynamics [222, 353] PEEP in general leads to an increase in interstitial fluid by facilitating peripheral transcapillary... problem being ineffective or wasted efforts [101] A trigger effort, in the vast majority occurring during the expiratory period, indicated by an abrupt decrease in airway pressure of >0.5 cm H2O is ineffective if not resulting in an assisted breath from the ventilator (if the trigger occurs during expiration, accompanied by a decrease expiratory flow) [99] Ineffective efforts, also known as ineffective... displaying a significant increase in the transpulmonary lung parenchyma distending pressure PTRANS, but leaving the pleural pressures unchanged as alveolar pressures are not transmitted [112], accordingly characterizing two subtypes of the same clinical picture, ALI/ARDS [112, 119, 127, 131, 132] Not to induce a misimpression, an increase in the total elastance of the respiratory system is, in the... etc.), V flow A beginning of inspiration (mechanical application of air), B peak pressure, C plateau pressure, D end-expiratory pressure, if positive called PEEP (Modified with permission from Rittner and Döring [146]) [112, 125] Gattinoni et al [118] established a linear relationship between increases in intra-abdominal pressures and chest wall elastance: ECW = 0.47 × intra − abdominal pressure ( cm... collapse and reopening of atelectatic areas and unstable alveoli [207, 208] as does volume inflation by putting strain on the terminal airways and gas exchange elements during inspiration [211, 214]; both processes disrupt pulmonary architecture leading to proinflammatory signalling by lung cells [122, 229, 269] Mechanical strain, such as over-­ distension [270, 271] and cyclic strain [272, 273], is