(BQ) Part 1 book Key topics in management of the critically ill presents the following contents: Simulation training in the intensive care unit, assessment and management of the delirious patient in the intensive care unit, management of stroke in a non neurointensive care unit, pain in intensive care,...
Key Topics in Management of the Critically Marcela P Vizcaychipi Carlos M Corredor Editors 123 Key Topics in Management of the Critically Ill Marcela P Vizcaychipi • Carlos M Corredor Editors Key Topics in Management of the Critically Ill Editors Marcela P Vizcaychipi Anaesthesia and Intensive Care Medicine Chelsea and Westminster Hospital London UK Carlos M Corredor Cardiothoracic Anaesthesia and Intensive St George’s Hospital London UK ISBN 978-3-319-22376-6 ISBN 978-3-319-22377-3 DOI 10.1007/978-3-319-22377-3 (eBook) Library of Congress Control Number: 2015954553 Springer Cham Heidelberg New York Dordrecht London © Springer International Publishing Switzerland 2016 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 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 The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made Printed on acid-free paper Springer International Publishing AG Switzerland is part of Springer Science+Business Media (www.springer.com) Foreword Intensive care medicine is a rapidly evolving specialty In the last decade, there have been advances in technology, diagnostics, treatment and in our understanding of the pathogenesis of diseases that affect critically ill patients Management of conditions such as burns, stroke, acute liver failure, thromboembolism and delirium have changed dramatically over the last few years with new diagnostic and therapeutic modalities These topics are eloquently covered in the relevant chapters in Key Topics in Management of the Critically Ill Physical and neuropsychological rehabilitation after intensive care has been another area of specific interest to the intensive care community over the last few years and covered in the chapter on Neuropsychological Rehabilitation for Critically Ill Patients Published literature report approximately 30 % of patients suffer from anxiety, 20 % of patients suffer from depression and up to 60 % of patients suffer from post-traumatic stress disorder after intensive care admission with the associated long-term socio-economic consequences Whereas historically intensive care physicians were satisfied to leave follow-up care of these patients to the community, there is now increasing recognition that early intervention during and immediately after intensive care admission can positively impact on recovery, length of hospital stay and healthcare costs In some countries, such as the United Kingdom, national guidance and policies have been developed to help address long-term physical and neuropsychological sequelae of critical illness The use of ultrasound and echocardiography are no longer limited to the remit of radiologists and cardiologists The increased portability, usability, and advanced technology of modern ultrasound and echocardiography machines mean that ultrasound and echocardiography are now routinely used by the bedside to help direct clinical care in modern day intensive care units Two chapters in this book are dedicated to the use of these important diagnostic modalities Finally, intensive care medicine is a multidisciplinary specialty that relies on effective teamwork, leadership, and communication to achieve best outcomes for patients The chapter on Simulation in Intensive Care highlights how simulation can be used effectively to enhance technical and non-technical skills (human factors) such as team dynamics, decision-making and situation awareness to improve patient safety, patient outcome and staff satisfaction through interdisciplinary training v vi Foreword Key Topics in Management of the Critically Ill offers a succinct guide to important topics in intensive care written by international experts in the field The chapters are designed to provide a comprehensive summary of the pertinent clinical, diagnostic and management principles for the practising intensive care clinician Dr Pascale Gruber, MBBS, BSc, MRCP, FRCA, EDIC, FICM Clinical Lead in Intensive Care, The Royal Marsden NHS Foundation Trust Chair of the Clinical Training Committee of the European Society of Intensive Care Medicine London, UK Contents Simulation Training in the Intensive Care Unit Alina Hua, Helen Williams, Naz Nordin, and Kevin Haire Assessment and Management of the Delirious Patient in the Intensive Care Unit 13 Valerie J Page and Annalisa Casarin Management of Stroke in a Non-neurointensive Care Unit 25 Ian Conrick-Martin and Áine Merwick Neuropsychological Rehabilitation for Critically Ill Patients 47 Olivia Clancy, Annalisa Casarin, Trudi Edginton, and Marcela P Vizcaychipi Pain in Intensive Care 63 Harriet Wordsworth and Helen Laycock Regional Anaesthesia in the Intensive Care Unit 75 Jacinda Gail Hammerschlag and Richard Peter von Rahden Dynamic Assessment of the Heart: Echocardiography in the Intensive Care Unit 87 Carlos M Corredor The Role of Lung Ultrasound on the Daily Assessment of the Critically Ill Patient 105 Nektaria Xirouchaki and Dimitrios Georgopoulos Acute Liver Failure: Diagnosis and Management for the General Intensive Care 117 Behrad Baharlo 10 The Initial Surgical Management of the Critically Ill Burn Patient 137 Jorge Leon-Villapalos 11 The Critically Ill Burn Patient: How Do We Get It Right? 155 Katherine Horner, Catherine Isitt, and Asako Shida vii viii Contents 12 Venous Thromboembolism Prevention and the Role of Non-Coumarin Oral Anticoagulants in the Intensive Care Units 167 Simona Deplano, Sheena Patel, Ian Gabriel, and Francis Matthey 13 Magnesium and Cell Membrane Stability in the Critically Ill Patient 179 Felicia Bamgbose and Pranev Sharma 14 Transfer of the Sickest Patient in the Hospital: When How and by Whom 189 Michael E O’Connor and Jonathan M Handy Contributors Behrad Baharlo, MBBS, BSc (Hons), FRCA Magill Department of Anaesthesia, Intensive Care Medicine and Pain Management, Chelsea and Westminster Hospital, London, UK Felicia Bamgbose Perioperative Research into Memory Group, Chelsea and Westminster Hospital, London, UK Annalisa Casarin Department of Anaesthesia, Watford General Hospital, Watford, UK Olivia Clancy, MD, FRCA Perioperative Research into Memory Group, Chelsea and Westminster Hospital, Imperial School of Anaesthesia, London, UK Carlos M Corredor, MBBS, MRCP, FRCA, FFICM Cardiothoracic Anaesthesia and Intensive Care, St George’s Hospital, London, UK Simona Deplano, MD, PhD Department of Haematology, Chelsea and Westminster Hospital, London, UK Trudi Edginton Department of Psychology, University of Westminster, London, UK Ian Gabriel, MD, MRCP Department of Haematology, Chelsea and Westminster Hospital, London, UK Dimitrios Georgopoulos Department of Intensive Care Medicine, University Hospital of Heraklion, Heraklion, Greece Kevin Haire, MD, FRCA Magill Department of Anaesthesia, Intensive Care Medicine and Pain Management, Chelsea and Westminster Hospital, London, UK Jacinda Gail Hammerschlag, BSc(Wits), MBBCh(Wits), FCA(SA) Department of Anaesthesia, Evelina London Children’s Hospital, St Thomas’s Hospital, London, UK Jonathan M Handy, BSc, MBBS, FRCA, EDIC, FFICM Magill Department of Anaesthesia, Chelsea and Westminster Hospital, London, UK Katherine Horner, BSc, MSc, MRes, MBBS, FRCA The Magill Department of Anaesthesia, Chelsea and Westminster Hospital, London, UK ix 7 Dynamic Assessment of the Heart: Echocardiography in the Intensive Care Unit 7.4 89 Standard Basic Windows A focused echocardiography examination of the critically ill patient should include two-dimensional (2D) images of the following views or windows (Fig 7.1), (Table 7.2): Parasternal long axis (PLAX) Parasternal short axis (PSAX) Apical chamber (A4C) Subcostal chamber Subcostal IVC Fig 7.1 Focused echocardiography transthoracic windows 90 C.M Corredor Table 7.2 Basic transthoracic echocardiographic windows, tips for obtaining each view and utility of each window Windows Parasternal long axis (PLAX) Parasternal short axis (PSAX) Apical four chamber (A4C) Obtaining this view Third to fourth intercostal space, left parasternal border Transducer index marker points to right shoulder Third to fourth intercostal space, left parasternal border Transducer index marker points to left shoulder Fourth to fifth intercostal space, midclavicular line Index marker points towards left Subcostal four chamber Transducer flat in epigastrium below ribs Index marker points towards left IVC subcostal Subxiphoid, index marker points to head Transducer tilts to the left of the patient • • • • Utility LV size and function RV size Pericardial and left pleural effusion Aortic dissection Aortic and mitral valve LV /RV size and function Pericardial effusions LV/RV size and function Mitral and tricuspid valves Atrial size (RA, LA) Pericardial effusion LV/RV size and function Mitral and tricuspid valves Atrial size Pericardial effusion Useful in mechanically ventilated patients IVC size and respiratory variation Parasternal long axis (PLAX) Parasternal short axis (PSAX) Apical four chamber (A4C) Subcostal four chamber (SC) and the inferior vena cava (IVC) 7.5 Goals of a Focused Critical Care Echo Examination A systematic examination using the standard views described above aims to answer the following questions: • • • • What is the Left Ventricle (LV) size and function? What is the Right Ventricle (RV) size and function? What is the fluid status (preload), and is there evidence of preload dependence? Is there a pericardial effusion? Is the effusion causing cardiac tamponade? Answering these questions at the bedside provides the clinician with non-invasive information to diagnose and guide treatment for the haemodynamically unstable critically ill patient Accurate Doppler-based measurements are challenging in the critically ill and often mechanically ventilated patient Therefore, focus should be placed in a systematic acquisition of good quality 2D images Any abnormality should be confirmed in at least two windows 7 Dynamic Assessment of the Heart: Echocardiography in the Intensive Care Unit Table 7.3 Normal left ventricle enddiastolic diameter (LVEDD) dimensions Male Normal (mm) Mild (mm) Moderate (mm) Severe (mm) 42–59 60–63 64–68 ≥69 91 Female 39–53 54–57 58–61 ≥62 7.5.1 Left Ventricular Assessment Accurate analysis of left ventricular size function is an essential first step when evaluating a critically ill patient presenting with shock The aim of the echo examination will be to determine if the left ventricle is: (Table 7.3) • Small • Normal size • Dilated: mild, moderate or severe The LV diameter is best measured in the PLAX window at the level of the tip of the mitral valve [13] The left ventricle end-diastolic diameter (LVEDD) is the largest cardiac dimension and should be obtained shortly before systole begins This corresponds to the beginning of the QRS complex or the frame just after mitral closure The following pitfalls should be avoided when measuring LVEDD: • Measurements should be taken between the endocardial borders, not the pericardium • Distance should be measured perpendicular to the long axis of the LV 2D measurements are preferred over M-mode for this reason • Avoid including papillary muscles or chordae in the measurements The most commonly used methods for assessment of LV function in the critical care setting are: • • • • Visual gestalt or ‘eyeballing’ Ejection fraction (EF) Fractional shortening (FS) Cardiac output (CO) 7.5.1.1 Visual Gestalt Estimation of EF is achieved by ‘eyeballing’ the overall size and contractility of the LV. The thickening and inward movement of the LV walls are assessed in 2D images with no formal measurements required The use of ‘eyeballing’ by intensivists with basic echocardiography training has been found to have a good level of agreement with LV function estimation performed by experienced echocardiographers [14] 92 Table 7.4 Normal values for ejection fraction (EF) C.M Corredor Normal Mild Moderate Severe >55 % 45–54 % 30–44 % 40 %) were present in fluid-responsive patients [32] 7 Dynamic Assessment of the Heart: Echocardiography in the Intensive Care Unit 99 7.6.3.2 Velocity Time Index Variation (VTI) The velocity time index (VTI) of flow through the left ventricular outflow tract (LVOT) and its variation with respiration can also be used for the assessment of preload dependence VTI value is obtained by placing a pulse-wave Doppler (PWD) sample volume in the LVOT just below the aortic valve The obtained waveform is traced, and a VTI value in centimetres is obtained VTI waveforms are obtained for three or four respiratory cycles Measurements of VTI are then obtained for the largest and smallest waveforms observed during a single respiratory cycle VTI variation (ΔVTI) is then calculated as follows: ∆VTi = VTImax − VTImin / VTI mean A study of mechanically ventilated septic shock patients found that a ΔVTI value of >12 % discriminated between responders and non-responders to volume expansion with a sensitivity of 100 % and specificity of 89 % [33] ΔVTI is able to predict fluid responsiveness even when a small volume of fluid or ‘mini’ fluid challenge of 100 mL is administered In a study performed in mechanically ventilated patients with acute circulatory failure, a 10 % increase in VTI following a 100 mL rapid bolus administration accurately predicted fluid responsiveness to further larger volume of fluids [34] 7.7 Evaluation of Pericardium and Tamponade The diagnosis of pericardial tamponade requires for fluid to be present in the pericardial space and for this fluid to cause a haemodynamic effect The basic echo window’s subcostal four-chamber, PLAX, PSAX and apical four- chamber views are useful for visualisation of pericardial fluid Effusions can be quantified as small (2 cm) [35] The size of the effusion is not the only factor determining the physiological effect of the fluid accumulated; the rate of accumulation is equally or more important The diagnosis of tamponade depends upon the demonstration of ‘tamponade physiology’, which occurs when the pressure inside the pericardial space surpasses that of the cardiac chambers impairing normal filling [36] Typical 2D echocardiographic characteristics of tamponade are RA systolic collapse, RV diastolic collapse, severe fixed dilatation of the IVC and variations of the RV and LV size with respiration 7.8 Echocardiographic Approach to the Patient with Shock Echocardiography can play an important role as a diagnostic tool and haemodynamic monitor in the patient presenting with haemodynamic instability There is wide agreement in recommending focused echocardiography in the early assessment of a patient presenting with shock [37] 100 C.M Corredor SHOCK CO estimation co=(VTIxCSA)xHR LOW High Volume/Filling pressures LOW IVC < 1.2cm LVEDD < 3cm IVCdi > 18%∗ ∆VTi > 12%∗ IVCci > 30% Hypovolemic Contractility Normal or hyperdynamic Chamber size: Small High IVC > 2cm LVEDD > 6cm IVCdi < 18%∗ ∆VTi < 12%∗ IVCci < 30% Cardiogenic Contractility poor Chamber size Large Obstructive Tamponade: Small ventricles,pericardial efussion PE: Dilated RV, SMALL LV Distributive Contractility Preserved Chamber size Normal Fig 7.7 Echocardiographic approach to the patient with shock algorithm CO cardiac output, VTI velocity time index at the LVOT left ventricle outflow tract, CSA cross-sectional area of the LVOT, IVC inferior vena cava, LVEDD left ventricle end-diastolic diameter, IVCdi IVC distensibility index, ΔVTi VTI variability index, IVCci IVC collapsibility index (*Mechanically ventilated patients only) Establishing rapidly the type and cause of shock allows for instigation of prompt and targeted treatment Echocardiography supplements, in a non-invasive manner, medical history, clinical examination and investigations Systematic estimation of volume status, systolic function and observation of chamber obstruction can complete the clinical picture in the diagnosis of shock There are four steps in the echocardiographic assessment of the patient in shock: 7 Dynamic Assessment of the Heart: Echocardiography in the Intensive Care Unit 101 Step 1: Estimation of the cardiac output by obtaining stroke volume through the Doppler examination of the LVOT flow signal Step 2: Assessment of volume status and filling pressures, which can be achieved by examining the size and respiratory variation indexes of the IVC. 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(Table 1. 1) [4] 1. 4 .1 Part- Task Training Part- task simulation training is the breaking down of a large, multicomponent task into simpler individualised elements This type of training focuses on the. .. Switzerland 2 016 M.P Vizcaychipi, C.M Corredor (eds.), Key Topics in Management of the Critically Ill, DOI 10 .10 07/978-3- 319 -22377-3_2 13 14 V.J Page and A Casarin Table 2 .1 Defining features of delirium... to clinical areas and may allow in situ training to become repetitive, and potentially a routine part of the working week (Fig 1. 4) 1 Simulation Training in the Intensive Care Unit Fig 1. 4 University