(BQ) Part 2 book Revision notes in intensive care medicine has contents: Perioperative care, organizational issues, dying, death, organ, and tissue donation; ethics, law, and communication, haematology,... and other contents.
CH A PTE R Infection CO NT ENTS Principles of infection 229 Antibiotics 231 Antivirals 241 Antifungals 243 Sepsis 245 Specific infections 255 Nosocomial infections 265 1 Principles of infection Infection is a common cause for ICU admission and a common complication of critical illness 1.1 Risk factors for infection in the critically ill 1.1.1 Patient factors ● ● Loss of natural barriers: ■ Tracheal intubation ■ Vascular access ■ Open wounds Reduction in immune function: ■ Drug-induced immunosuppression ■ Disease-induced immunosuppression ■ Nutritional state 1.1.2 Environmental factors (on the ICU) ● ● Relative overcrowding: ■ Multiple complex patients in one area Multiple staff contacts: ■ Complex patients requiring input from many professionals 1.1.3 Organisms ● Resistant organisms more common in the ICU environment: ■ High antibiotic use ■ Infection itself more common 1.2 Biomarkers of infection ● ● Most intensive care patients are inflammatory at some point in their admission Not all inflammation is secondary to sepsis 230 Chapter 6 Infection ● ● ● It is desirable to differentiate between infective and non-infective causes of an inflammatory response, primarily for the purposes of antibiotic stewardship ‘Traditional’ markers, such as white cell count and c-reactive protein (CRP), have no capacity to differentiate between infective and non-infective inflammation The ‘ideal’ biomarker of infection would: ■ Differentiate between infective and non-infective causes ■ Rise and fall in line with clinical picture, with minimal time-lag ■ Allow quantification of the severity of infection 1.2.1 Procalcitonin ● ● ● ● ● ● Procalcitonin (PCT) is the precursor to calcitonin, synthesized in the thyroid C cells In presence of bacterial infection, PCT is synthesized in neurohumeral tissues throughout the body PCT is relatively specific to bacterial infection, although short-lived, small rises are seen in the context of major trauma and surgery PCT rises as early as hours post-bacteraemia, compared to 36 hours with CRP The area under the Receiver Operator Curve for a PCT >2ng.ml–1 in diagnosis of bacterial infection has been reported as 0.82 Interpretation of the PCT result, and decisions regarding antibiotics, must however be made in the context of the clinical picture 1.2.2 Broad-range bacterial PCR (16s) ● ● ● This test utilizes polymerase chain-reaction techniques to identify the ribosomal RNA of bacteria The need to grow bacteria in the laboratory is therefore negated; this is particularly useful for those organisms resistant to in vitro growth The test can be applied to any sample (blood, sputum, pleural fluid, etc.) 1.2.3 β-D Glucan ● ● β-D glucan is a component in most fungal cells walls Detection of β-D glucan in plasma is highly suggestive of invasive fungal infection 1.2.4 Galactomannan ● ● Galactomannan is a component of the cell wall of Aspergillus sp Detection of galactomannan in plasma is highly suggestive of invasive Aspergillus 1.3 Failure to respond to treatment ● Apparent failure of infection to respond to treatment may be due to numerous factors 1.3.1 Patient-related ● ● ● Co-morbidity: ■ Directly impeding recovery from infection (e.g bronchial neoplasm in non-resolving pneumonia) ■ Indirectly impeding recovery from infection (e.g neuromuscular weakness in non-resolving pneumonia) Immunosuppression: ■ Pathological (e.g HIV) ■ Pharmacological (e.g immunosuppressant medication; bone marrow suppression) Ongoing contamination of sterile site (e.g micro-aspiration; enteral leak) Antibiotics 231 1.3.2 Antibiotic-related ● ● ● Wrong antibiotic: ■ Bacteria not sensitive ■ Inadequate tissue penetration to the site of infection Inadequate dose or frequency leading to sub-therapeutic plasma levels Antibiotic inactivation by bacteria (e.g beta lactamase) 1.3.3 Disease-related ● ● ● ● ● Non-bacterial infection Non-infective inflammatory process Unrecognized secondary infection Lack of source control Development of collection (e.g empyema in pneumonia, abscess in pancreatitis) 1.4 Infection control ● Prevention and management of resistant organisms 1.4.1 Organizational ● ● ● Antibiotic policy: ■ Narrow spectrum ■ Limited formulary for non-specialist staff ■ Infectious disease/microbiology involvement Surveillance and eradication Audit and quality assurance 1.4.2 Local ● ● ● ● Avoidance of inappropriate antibiotics Rigorous hand washing Contact precautions Cohorting of infected patients FURTHER READING Dupuy A-M, Philippart F, Péan Y, et al Role of biomarkers in the management of antibiotic therapy: an expert panel review: I–currently available biomarkers for clinical use in acute infections Annals of Intensive Care 2013; 3(1): 22 Kibe S, Adams K, Barlow G Diagnostic and prognostic biomarkers of sepsis in critical care Journal of Antimicrobial Chemotherapy 2011; 66(Suppl 2): ii33–40 2 Antibiotics 2.1 Principles of antibiotics in intensive care ● ● Antimicrobials are a class of agents used to kill or suppress microorganisms Antibiotic is a specific term for a substance produced by a microorganism, which has the capacity to kill or inhibit the growth another microorganism 232 Chapter 6 Infection 2.1.1 Roles of antibiotics ● ● ● Treatment of infection: ■ Empirical ■ Targeted Prophylaxis: ■ Selective digestive decontamination Non-antimicrobial role: ■ E.g erythromycin as a prokinetic 2.1.2 Principles of use ● ● ● Right agent—ideally guided by direct microbiological evidence; empirical therapy should be guided by local infection and resistance patterns Right time—early, within hour of severe sepsis recognition Right duration—empirical antibiotics should be switched as early as possible 2.1.3 Pharmacology of antibiotics in critical illness ● ● Pharmacokinetics studied primarily in healthy volunteers Critical illness impacts upon: ■ Absorption: ■ Gut oedema ■ Impaired gut function ■ Impaired splanchnic blood flow ■ Distribution: ■ Oedema and extra-corporeal circuits increase volume of distribution ■ Protein binding (which Impacts upon half-life and free drug availability): ■ Reduced protein availability ■ Acid–base derangement ■ Variable drug binding to extra corporeal circuits ■ Clearance: ■ Hepatic impairment reduces metabolism ■ Biliary obstruction impairs hepatic excretion ■ Renal impairment reduces renal excretion 2.1.4 Antibiotic dosing regimens ● The desired plasma levels vary between antibiotic classes but tend to fall into one of three patterns: ■ Maximum concentration dependent (Cmax:MIC): ■ E.g aminoglycosides, metronidazole ■ Efficacy dependent upon the peak plasma concentration ■ Bolus dosing regimen ■ Time above ‘minimum inhibitory concentration (MIC)’ dependent (T>MIC): ■ E.g penicillins, carbapenems, linezolid, clindamycin ■ Efficacy dependent upon the proportion of time with plasma concentrations greater than MIC ■ Frequent dosing or continuous infusion utilized ■ Time and concentration dependent: ■ E.g quinolones ■ Area under the curve above the MIC line is the most important marker of efficacy (AUC:MIC) Antibiotics 233 2.1.5 Antibiotic resistance ● ● ● May be inherent or acquired: ■ Inherent—a natural resistance (e.g the outer membrane surrounding Gram-negative bacteria is impenetrable to many antibiotics) ■ Acquired—the modification of existing genetic material to provide resistance Mechanisms include: ■ Inactivation of antibiotic by bacterial enzyme, either degradation of the antibiotic or modification of activity (e.g beta-lactamase) ■ Decreased target site penetration (e.g impaired bacterial penetration or active efflux from the cell) ■ Altered target site (e.g alteration of the protein binding site in MRSA confers resistance to penicillins) Resistance mechanisms are frequently encoded in bacterial plasmids and therefore potentially transmissible between bacteria (horizontal gene transfer) 2.2 Beta lactams 2.2.1 General ● ● Most commonly used group of antibiotics Defined by the presence of a ‘beta-lactam ring’ within molecular structure 2.2.2 Pharmacokinetics ● ● ● ● Absorption ■ Variable ■ Many beta lactams are available only in the parenteral form Distribution ■ Variable protein binding: ■ Ampicillin 20% ■ Flucloxacillin 90% ■ Generally good tissue penetration but requires inflammation to penetrate central nervous system or bone Metabolism ■ Excreted mostly unchanged Excretion ■ Relatively short half-life (generally hour or less with normal renal function) ■ Primarily renal excretion ■ Probenecid blocks active tubular excretion and therefore increases plasma levels of most beta lactams ■ Dose adjustment may be required in renal impairment, particularly benzylpenicillin and piperacillin ■ Clearance via RRT is variable; dependent upon degree of protein binding (e.g ampicillin undergoes greater clearance with RRT than flucloxacillin) ■ Plasma concentration of beta-lactams should be 4–5 times MIC and plasma levels should be maintained as long as possible between doses ■ For this reason, in ICU beta lactams are often delivered as infusion rather than bolus dose 2.2.3 Pharmacodynamics ● Bactericidal—beta-lactam ring binds to and inhibits bacterial transpeptidases thereby inhibiting cell wall synthesis: 234 Chapter 6 Infection ■ ■ Gram-positive bacteria ■ Beta lactams weaken the thick glycopeptide wall, killing bacteria ■ Synergistic effect with aminoglycosides (beta lactams will allow better aminoglycoside penetration) ■ They lack post-antibiotic effect Gram-negative bacteria ■ Beta lactams weaken the thin glycopeptide wall and liposacharide envelope ■ Cell death dependent upon osmotic influx of water 2.2.4 Adverse effects ● ● ● ● ● Hypersensitivity—allergy in approximately 10% of cases; anaphylaxis in approximately 0.01% of cases Encephalopathy—benzylpenicillin, particularly when CNS levels high (i.e large doses in meningitis, renal dysfunction, and probenecid use) Reduction in seizure threshold—particularly benzylpenicillin and the carbapenems Rash—particularly ampicillin; 10% of patients, rises to 95% in infectious mononucleosis Gastrointestinal—diarrhoea; 0.3–0.7% incidence of pseudomembranous colitis 2.2.5 Penicillins ● ● ● ● ● Further subdivided into: ■ Narrow-spectrum penicillins—e.g benzypenicillin ■ Narrow-spectrum penicillins with beta-lactamase resistance—e.g flucloxacillin ■ Extended spectrum penicillins—e.g ampicillin ■ Anti-pseudomonas penicillins—e.g piperacillin Benzylpenicillin: ■ Narrow spectrum ■ Inactivated by gastric acid, therefore must be administered parenterally ■ Typically effective against a wide range of Gram-positive bacterial, Gram-negative cocci, and some Gram-negative bacilli ■ Typically ineffective against Staphylococcus, Haemophilus influenza, and Pseudomonas spp Flucloxacillin: ■ A synthetic penicillin with moderate resistance to beta lactamase ■ Well absorbed via oral route ■ More effective than benzylpenicillin against Staphylococcus; less effective against other Gram-positive cocci ■ Highly protein bound; limited clearance on RRT ■ Can cause cholestatic jaundice Ampicillin/amoxicillin: ■ Same range of effectiveness as benzylpenicillin, with greater Gram-negative bacilli cover (Haemophilus influenza spp., Salmonella, Escherichia coli, Enterococcus faecalis— although increasing resistance to the latter) ■ Amoxicillin provides superior bioavailability (therefore may be administered orally); also bactericidal to Gram-negative bacteria at lower concentrations ■ The addition of clavulanic acid to amoxicillin irreversibly inhibits a wide range of beta lactamases and reduces the MIC Piperacillin: ■ Broader spectrum but less potent than benzylpenicillin Antibiotics 235 ■ ■ Particularly effective against Pseudomonas spp., Serratia, and Citrobacter Beta-lactamase sensitive, therefore combined with beta-lactamase inhibitor tazobactam (which, unlike clauvanic acid, has no intrinsic anti-microbial activity) 2.2.6 Cephalosporins ● ● ● ● ● Cephalosporins are a broad and widely used group of beta-lactam antibiotics Cephalosporins combine a beta-lactam ring with a hydrothiazide ring Less susceptible to beta lactamase Wide distribution, particularly effective at crossing inflamed membranes (e.g ceftriaxone and inflamed meninges) Classified into successive generations; with each successive generation, Gram-positive cover is maintained, Gram-negative cover improves; some later generations demonstrate activity against Pseudomonas spp ■ First-generation cephalosporins: ■ E.g cefradine ■ Effective against beta-lactamase producing Staphylococci, Streptococci, and anaerobic Gram-positive cocci ■ Second-generation cephalosporins: ■ E.g cefuroxime ■ More resistant to beta lactamase; increased Gram-negative activity (H influenza, Neisseria gonorrhoeae, Klebsiella pneumoniae, and Enterobacter spp.) ■ Widespread resistance to E faecalis, Acinobacter, Serratia, and Pseudomonas spp ■ Useful agents for abdominal cover but additional anaerobic cover required ■ Third-generation cephalosporins: ■ E.g ceftriaxone, cefotaxime ■ Improved Gram-negative cover but slightly less effective against Gram-positive bacteria ■ Typically effective against Acinetobacter and Serratia ■ Ceftazidime is effective against Pseudomonas, although limited Staphylococcus cover ■ The long half-life of ceftriaxone allows once daily dosing ■ Fourth-generation cephalosporins: ■ Cefepime ■ Similar Gram-negative cover to ceftazidime (including anti-pseudomonal cover) but better Gram-positive cover ■ Fifth-generation cephalosporins: ■ Ceftaroline ■ Similar Gram-positive and negative cover to cefotaxime but with activity against methicillin-resistant Staphylococcus aureus 2.2.7 Carbapenems ● ● ● The broadest spectrum of any antimicrobial with Gram-positive, Gram-negative aerobic and anaerobic cover Best administered as prolonged infusions (3 hours) Imipenem: ■ Very broad spectrum (although only moderate cover for Citrobacter, Enterobacter spp and Serratia) ■ Partially metabolized by renal dehydropeptidase; cilastatin given concurrently to block this metabolic pathway 236 Chapter 6 Infection Excreted unchanged in urine; accumulates in renal failure; dose alteration required with renal replacement therapy ■ Hepatotoxicity—self-limiting rise in transaminase levels and cholestatic jaundice occur in 5–10% of patients; may be latency of onset of several days; acute liver failure has been reported Meropenem: ■ Similar profile to imipenem but does not require concurrent cilastatin administration ■ Some increase in Gram-negative cover but reduction in Gram-positive cover ■ ● 2.3 Macrolides 2.3.1 General ● Similar range of activity to penicillins: ■ Most Gram-positive bacteria ■ N meningitides ■ H influenza ■ Some anaerobes ■ Also have specific cover against Mycoplasma pneumoniae and Legionella 2.3.2 Pharmacokinetics ● ● ● ● Absorption ■ Good oral bioavailability Distribution ■ Good lung but limited CSF penetration ■ Variable protein binding Metabolism ■ Metabolized primarily by the liver Excretion ■ Significant amount excreted unchanged, therefore dose reduction required in kidney injury 2.3.3 Pharmacodynamics ● ● Primarily bacteriostatic Bind to the 50s ribosomal subunit preventing replication 2.3.4 Adverse effects ● ● ● Gastrointestinal effects common (nausea, diarrhoea, hepatic dysfunction); prokinetic effect, which may be used for therapeutic purposes Cardiovascular—prolong QT interval Drug interaction—augment the effect of theophylline, warfarin, and digoxin 2.3.5 Specific agents ● ● Erythromycin: ■ Parent compound ■ Marked gastrointestinal effects: commonly used as a prokinetic agent (including prior to gastroscopy for suspected haemorrhage to improve visualization) Clarithromycin: ■ Fewer gastrointestinal effects ■ Superior activity against Streptococcus, Listeria, and Legionella than erythromycin Antibiotics 237 ● Azithromycin: ■ Improved bioavailability ■ Longer half-life allows once daily dosing ■ Better Gram-negative cover 2.4 Aminoglycosides 2.4.1 General ● ● ● ● ● A large group of antibiotics, of which only gentamicin, amikacin, neomycin, and tobramycin are in routine clinical use Wide Gram-negative cover Some Gram-positive cover (e.g Staphylococci, some Streptococci) No anaerobic activity Synergistic activity with beta lactams and vancomycin 2.4.2 Pharmacokinetics ● ● ● ● Absorption ■ No absorption from gastrointestinal tract, therefore parenteral only Distribution ■ Large polar molecules ■ Low protein binding (20–30%) ■ Distribution is limited; poor intracellular, CSF, and sputum penetration Metabolism ■ Not metabolized ■ Aminoglycoside molecules are large and polar; active transport is required to access bacterial cells Transport mechanisms may be inhibited by: ■ Divalent cations (Mg2+, Ca2+) ■ Acidosis ■ Hypoxia Excretion ■ Excreted unchanged in urine 2.4.3 Pharmacodynamics ● ● ● ● Bactericidal Bind to the ribosomal 30s subunit, blocking protein synthesis They have significant post-antibiotic effect Administered as single doses with extended interval dosing 2.4.4 Adverse effects ● ● ● ● Narrow therapeutic range Ototoxicity may occur if significant aminoglycoside accumulation in the perilymph; risk is related to peak plasma concentrations and increased by renal dysfunction and concurrent use of furosemide Nephrotoxicity: acute tubular necrosis occurs in up to 37% of intensive care patients given gentamicin Muscular weakness—aminoglycosides reduce the pre-junctional release and post-junctional sensitivity of acetylcholine at the neuromuscular junctions; effect of non-depolarizing muscle relaxants is extenuated; aminoglycosides should be avoided in myasthenia gravis 238 Chapter 6 Infection 2.5 Quinolones 2.5.1 General ● See individual agents for cover (Section 2.5.5) 2.5.2 Pharmacokinetics ● ● ● ● Absorption ■ Good absorption, reduced by concurrent administration of magnesium, calcium, and iron Distribution ■ Wide distribution with excellent penetration of the CSF ■ Limited protein binding Metabolism ■ Limited metabolism Excretion ■ Largely excreted unchanged 2.5.3 Pharmacodynamics ● ● ● Bactericidal Inhibits subunit of DNA-gyrase They some significant post-antibiotic effect 2.5.4 Adverse effects ● ● ● ● Reduction of seizure threshold Nausea, vomiting, and abdominal pain Haemolysis in the presence of glucose-6-phosphatase deficiency Interaction, e.g increases plasma theophylline levels 2.5.5 Specific agents ● ● ● Ciprofloxacin: ■ Most commonly used quinolone ■ Broad Gram-negative cover, including Pseudomonas; some Gram-positive cover (Streptococcus, Enterococcus) ■ Available in oral and intravenous preparations ■ Agent of choice for anthrax (with clindamycin) and pneumonic plague Norfloxacin: ■ Oral only ■ Prophylaxis against spontaneous bacterial peritonitis in patients with cirrhosis Levofloxacin: ■ Intravenous agent ■ Similar cover to ciprofloxacin with improved pneumococcal cover ■ Effective against legionella 2.6 Metronidazole 2.6.1 General ● Potent inhibitor of obligate anaerobes and protozoa ■ Active against Clostridium spp., Bacteroides spp., Treponema pallidium, and Campylobacter 450 Key papers TRICC Hebert PC, Wells G, Blajchman MA, et al A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care New England Journal of Medicine 1999; 240: 409–17 TRISS Holst LB, Haase N, Wetterslev J, et al Lower versus higher hemoglobin threshold for transfusion in septic shock New England Journal of Medicine 2014; 371: 1381–91 TTM Nielsen N, Wetterslev J, Cronberg T, et al Targeted temperature management at 33°C versus 36°C after cardiac arrest New England Journal of Medicine 2013; 369(23): 2197–206 Van den Berghe study Van den Berghe G, Woulters P, Weekers F, et al Intensive insulin therapy in the critically ill patients New England Journal of Medicine 2001; 34519: 1359–67 VASST Russell JA, Walley K.R, Singer J, et al Vasopressin versus norepinephrine infusion in patients with septic shock New England Journal of Medicine 2008; 358(9): 877–87 VISEP Brunkhorst FM, Engel C, Bloos F, et al Intensive Insulin Therapy and Pentastarch Resuscitation in Severe Sepsis New England Journal of Medicine 2008; 358(2): 125–39 Index Tables, figures and boxes are indicated by an italic, t, f and b following the page number A A–a gradient 12 abdominal aortic aneurysm repair 435 abdominal compartment syndrome 181–3 abdominal perfusion pressure 181 acid 135 acid–base theories 136–8 acidosis, metabolic 136–7 Acinetobacter baumannii 268 action potential, cardiac 89–90 activated charcoal 329 activated clotting time 290 activated protein C 253–4 actual base excess 136 acute chest crisis 293 acute coagulopathy of trauma 281 acute coronary artery occlusion 100 acute coronary syndromes 98–100 acute heart failure 103–5 acute kidney injury 111–21 acute liver failure 153 aetiology 113–14 complications 112–13 definition 111–12 detection 114 drug-related 114 epidemiology 111 fluid therapy 117 follow-up 119 haemodynamic support 117 history 117–18 investigations 118 nephrology referral 118 outcomes 111 pathophysiology 114 prevention 115 renal replacement therapy 118 resuscitation 116–17 risk factors 113 urology referral 118 acute liver failure 151–6 acute kidney injury 153 aetiology 151t, 152–3 coagulopathy 153, 155 clinical manifestations 153–4 defining features 152t definition 152 emergency liver transplantation 155, 156t encephalopathy 153–4, 155 management 154–6 raised intracranial pressure 155 timing 152 acute liver failure early dynamic (ALFED) model 155 acute pancreatitis 177–81 Acute Physiology and Chronic Health Evaluation (APACHE) 179, 392–3 acute respiratory distress syndrome (ARDS) 40–4, 116 acute tubular necrosis 114 acyclovir 241–2 adenosine 95t admission scores 392–4 adrenaline 80t endotherapy 168 adrenal system 148–50 advanced directives 414–15 advanced life-support algorithm bradycardia 93f tachyarrhythmia 94f aggregated parameter track and trigger systems 389 AIDS-defining illnesses 258–9b air transport 402t airway advanced manoeuvres 28–31 basic manoeuvres 27 452 Index airway (continued) burns 315–16 emergencies 30–1 obesity 406 old age 404 paediatrics 403 pregnancy 347 spinal cord injury 306–7, 310–11 airway pressure release ventilation 24 akinetic mutism 194t albumin 137, 160 alcohol poisoning 336–7 ALFED model 155 alfentanil 192t allied professionals 387–8 α2 receptor agonists 191t altitude 402–3 alveolar–arterial (A–a) gradient 12 alveolar dead space alveolar ventilation 6–7 American Society of Anesthesiologists Physical Status Classification (ASA) score 424, 425t American Spinal Injury Association (ASIA) classification 304 aminoglycosides 237, 363 aminophylline 47t, 50t amitriptyline 192t amniotic fluid embolus 361–2 amoxicillin 234 amphotericin B 244 ampicillin 234 amyl nitrate 338 anaemia 275–6 anaemic hypoxia analgesics 192 anatomical dead space anidulafungin 244 anion gap 137 antepartum haemorrhage 359–60 anterior cord syndrome 304 anti-arrhythmic drugs 94–5 antibiotics 231–41 acute pancreatitis 180 agents 233–41 asthma 47t COPD 50t dosing regimens 232 meningitis prophylaxis 227 pharmacology 232 pneumonia 55 pregnancy 363 resistance 233 anti-cholinergic toxidrome 331t anticoagulation lumbar puncture 224 pulmonary embolus 58 renal replacement therapy 125–6 reversal 289 antifungals 243–5 antihypertensives 102t antivirals 241–3 ANZICS-CORE 397 aortic dissection 102–3 aortic surgery 435–7 aorto-caval compression 348 APACHE 179, 392–3 apparent strong ion difference 138 area under the receiver operator curve 392 L-arginine 186 arrhythmias 88–98 anti-arrhythmic drugs 94–5 bradyarrhythmia 91–2, 93f, 95t, 430 electrical conduction 90–1 post-cardiac surgery 430, 434t tachyarrhythmia 92, 94t arterial catheter 67 arterial waveform 67–8 artesunate 257 ASA score 424, 425t ascites 161–2 ASIA classification 304 aspirin poisoning 333 stroke 210 asthma 46–9 Atlanta criteria 177 atrial fibrillation 90, 92, 430 atrial flutter 90 atrio-ventricular node conduction abnormalities 91 atrio-ventricular node re-entrant tachycardia 91 Australia and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation (ANZICS-CORE) 397 autonomic dysreflexia 308 auto PEEP 48 azithromycin 237 azoles 243 B bacteraemia 246 base 136 base excess 136 bed space 385–6 benzodiazepines 191t benzylpenicillin 234 Berlin criteria 40t best interests 413 beta agonists 43t, 47t beta blocker poisoning 340–2 β-D glucan 230 beta lactams 233–6, 363 Index 453 biliary leak 165 biochemistry 66–7 biomarkers of infection 229–30 biomedical ethics 411 birth on ICU 351 bispectral index 208 blood glucose target 140 blood pressure arterial waveform 68 shock 63 target in sepsis 249 body temperature control 320 botulism 261–2 bradyarrhythmia 91–2, 93f, 95t, 430 brain death 372–3 herniation 199 post-anoxic prognostication 108, 109t tissue oxygenation sensor 204 see also traumatic brain injury brainstem death 373b breast-feeding 351 broad-range bacterial PCR 230 bronchopleural fistula 61 bronchoscopy 39, 62 Brown–Sèquard syndrome 305 bundle branch block 91 burns 314–18 C Caesarean section 352 calcium channel antagonist poisoning 340–2 CAM-ICU 221t capacity 412–14 capnography 13, 30b capnometry 13 capture threshold 97 carbapenem-resistant enterobacteriaceae 268 carbapenems 235–6 carbon dioxide difference between venous and arterial pCO2 67 monitoring 13 carbon monoxide poisoning 45, 338–9 cardiac action potential 89–90 cardiac arrest 105–9 management 106 maternal 351–2 post-cardiac arrest syndrome 106 prognostication 108, 109t cardiac assist devices 87, 88t, 105 cardiac filling pressure 74 cardiac output monitoring 69–73 cardiac pacing 96–8 cardiac surgery 116, 428–32, 433–4t cardiac tamponade 430, 431, 434t cardiogenic shock 65 cardioplegia 429 cardiopulmonary bypass 429–30 cardiopulmonary exercise testing 425 cardiopulmonary resuscitation decisions 416–17 cardio-respiratory interactions 74–5 cardiovascular assessment and monitoring 65–78 cardiovascular support 79–88 Case Mix Programme (Database) 397 caspofungin 244 catatonia 195t catheter-related blood stream infections 268–71 cauda equina lesion 305 caval filter 58 cefepime 235 cefotaxime 235 cefradine 235 ceftaroline 235 ceftriaxone 235 cefuroxime 235 cellulitis 264 central cord syndrome 304 central line associated bloodstream infection 269 central nervous system infections 223–8 central pontine myelinolysis 129 central venous catheters 268–71 central venous oxygen saturation 66 cephalosporins 235 cerebral perfusion 197–9 cerebral perfusion pressure 196 cerebral salt-wasting 206 cerebral spinal fluid analysis 223–5 chain of survival 106 chest drains 299b Child–Pugh–Turcotte score 157, 158t cholinergic toxidrome 330t chronic kidney disease 119–20 chronic liver failure/cirrhosis 156–63 aetiology 151t ascites 161–2 cardiovascular changes 156–7 defining features 152t hepatic encephalopathy 162–3 mortality scoring 157–8 renal dysfunction 159–61 chronic obstructive pulmonary disease (COPD) 49–51 ciprofloxacin 238 circulatory death 372 cirrhosis, see chronic liver failure/cirrhosis citrate anticoagulation 126 clarithromycin 236 clearing the spine 312 clindamycin 240, 363 clonidine 191t 454 Index Clostridium botulinum 261 Clostridium difficile 175 Clostridium tetani 262 CNS infection 223–8 coagulopathy 287–92 acute liver failure 153, 155 anticoagulation-induced 289 lumbar puncture 224 plasma component transfusion 288 point-of-care testing of coagulation 290–1 pre-eclampsia/eclampsia 358 trauma 281, 300 cocaine overdose 103 cold ischaemia time 375 cold water immersion 323 coma 153–4, 193, 194t coma-like states 194–5t communicating hydrocephalus 214 communication donation conversations 381–2 end-of-life care 370–1 family meetings 420–2 community-acquired pneumonia 51, 53, 55 compartment syndrome, abdominal 181–3 competence 412–14 compliance 10 computed tomography (CT) 300–1, 311 conduction action potential 89–90 Confusion Assessment Method for the ICU (CAM-ICU) 221t Conn’s syndrome 129, 130 consent 412–14 continuous renal replacement therapy 123–4 contrast, iodinated 115 contrecoup injury 196 conus medullaris syndrome 305 cooling methods 322–3 coronary artery occlusion 100 cor pulmonale 57–8 corrected sodium 142 corticosteroids, see steroids craniectomy 438 craniotomy 437 critical illness myoneuropathy 219–20 critical illness-related corticosteroid insufficiency (CIRCI) 149–50 cruciate paralysis 304 cryoprecipitate 288 Cryptococcus neoformans 261 CSF analysis 223–5 CT imaging 300–1, 311 CURB 65 score 53t Cushing’s response 199 cyanide poisoning 45, 337–8 cytotoxic hypoxia cytotoxic therapy 116 D damage control resuscitation 300 damage-control surgery 300 damping 67 dantrolene 323 dead space 6–7 death 371–4 care of the dying 368–70 diagnosis of 371 family considerations 370–1, 373, 374 maternal 352–4 neonatal 353 process 367–8 withdrawal of cardio-respiratory support 370–1 decision-making 417–20 documentation 419–20 fluid therapy 76f patient-centred 418 resuscitation 416–17 decompressive craniectomy 203t, 210 decontamination of the digestive tract 273–4 deferoxamine 340 delayed cerebral ischaemia 214–15 delirium 220–3 deprivation of liberty (DoLS) 415–16 deteriorating patients systems 388–90 dexmedetomidine 191t, 192 diabetes insipidus 129, 130, 205–6 diabetic ketoacidosis 140–2 diarrhoea 174–6 diary-keeping 409 diazepam 191t dichrotic notch 68 dicobalt edetate 338 dieticians 387 Difficult Airway Society algorithm 31f digoxin 95t poisoning 342–3 discharge from ICU 407–10 disease-specific scores 395–6 disproportionate care 411 disseminated intravascular coagulation 288–9 distributive shock 65 dobutamine 81t dopamine 81t Doppler ultrasound 72–3, 204 doxapram 50t drains chest 299b extra-ventricular 201, 214 for paracentesis 162b spinal 437 drowning 318–20 drug-related conditions acute kidney injury 114 acute liver failure 152–3 Index 455 coagulopathy 289 diarrhoea 176 hypercalcaemia 134 hyperkalaemia 131 hyperthermia 321–2 hypocalcaemia 134 hypomagnesaemia 133 hyponatraemia 128 platelet dysfunction 286 thyroid axis 146t dying, see death dynamic compliance 10 dynamic hyperinflation 48 E early rehabilitation 409 Eaton–Lambert syndrome 262 echinocandins 244–5 echocardiography 77–8 eclampsia 354–8 ectopic pregnancy 358–9 effective strong ion difference 138 elastance 10 elderly patients 404–5 electrocardiogram (ECG) 90–1 electroencephalogram (EEG) 208, 209t electrolytes 127–35 embolectomy 59 embolus amniotic fluid 361–2 pulmonary 56–9 emergencies airway-related 30–1 hypertensive 102–3 liver transplantation 155, 156t encephalitis 227–8 encephalopathy hepatic 153–4, 155, 162–3 hypertensive 101 end-of-life care 368–71, 380–2 endoscopic band ligation 171–2 endoscopic retrograde cholangiopancreatography 180 endotoxins 265 endotracheal intubation 28 failed 30–1 endovascular aneurysm repair 435–6 endovascular coiling 214t energy requirements 184 enhanced recovery after surgery (ERAS) 427–8 enteral nutrition 176, 185–6 Enterococcus, vancomycin-resistant 267 ephedrine 83t epicardial pacing 96t erythromycin 236 esmolol 102t ethanol poisoning 336–7 ethical principles 411 ethylene glycol poisoning 336–7 etomidate 191t expiration 15t expiratory hold 48 extended sigh 21 extended-spectrum beta-lactamase-producing enterobacteriaceae 268 extracorporeal membrane oxygenation 25–7, 87, 88t extra-ventricular drain 201, 214 extubation failure 36 post-extubation stridor 36–7 exudates 60 eye donation 379–80 F family considerations death and dying 370–1, 373, 374 family meetings 420–2 organ donation 376–7, 379, 380–2 post-intensive care syndrome 409 FAST scan 301 fentanyl 192t fidaxomicin 175 first-degree heart block 91 Fisher scale 213t fistula, bronchopleural 61 fixed performance mask 14 fixed-wing aircraft 402t FloTrac 72 flucloxacillin 234 fluconazole 243 fluid challenge 75 fluid therapy acute kidney injury 117 burns 316 decision-making 76f hypothermia 325 intracranial surgery 439 post-cardiac surgery 431 sepsis 249–52 Focused Assessment with Sonography in Trauma (FAST) scan 301 foetal assessment 350 foeto-maternal haemorrhage 365 follow-up clinics 410 fondiparinux 58 forced alkaline diuresis 329–30 Frank–Starling curve 75f free flap surgery 440–1 free water deficit 130 freeze-dried products 288 frequency 15t 456 Index fresh frozen plasma 288 fulminant colitis 175 fulminant liver failure, see acute liver failure G gabapentin 192t galactomannan 230 gallstone pancreatitis 180 gancyclovir 241–2 gas-trapping 48 gastric lavage 329 gastrointestinal haemorrhage 165–74 non-variceal 165–8, 173t small or large bowel 173–4 stress ulceration 168–9 variceal 170–2, 173t gastroscopy 167 gentamicin 237 Glasgow Blatchford Score 166 Glasgow Coma Score (GCS) 195t Glasgow–Imrie score 179 glucagon 83t, 341 β-D glucan 230 glutamine 186 glycaemic control 139–45 glyceryl trinitrate 102t, 104 glycopeptides 239–40 graft dysfunction 164 Gram-negative bacilli, multidrug-resistant 268 guanosine analogues 241–2 Guillain–Barre syndrome 218–19 gut decontamination 329 H HAART 259 haematological malignancy 294–6 haemodiafiltration 122 haemodialysis 121–2 intermittent 124 haemofiltration 121 haemolysis 279–80 haemolytic uraemic syndrome 285–6 haemoperfusion 330 haemoptysis 61–2 haemorrhage antepartum 359–60 foeto-maternal 365 gastrointestinal 165–74 intracerebral 211–12 major 280–2 obstetric 358–60 postpartum 360 subarachnoid 212–16 Haldane effect 10 healthcare associated pneumonia 53 heart block 91 heart failure, acute 103–5 heat exhaustion 321 heat oedema 321 heat-related injury 320–3 heatstroke 321 heat syncope 321 helicopters 402t heliox 47t HELLP syndrome 356–7 Henderson–Hasselbalch equation 136 heparin-induced thrombocytopenia 284, 285t hepatic artery thrombosis 165 hepatic encephalopathy 153–4, 155, 162–3 hepatorenal syndrome 159, 160b high dose insulin therapy 341–2 high flow nasal cannulae 14–15 high-frequency oscillatory ventilation 22–4 highly active antiretroviral treatment 259 high-risk surgical patients 423–4 Hill–Burton formula 385 HIV 258–61 hospital acquired pneumonia 51 hospital episode statistics procedure groups 425 Hudson mask 14 hydrocephalus 214 hydroxocobalamin 338 hypercalcaemia 134–5 hyperdynamic shock 65 hyperglycaemia 139 hyperkalaemia 131 hypermagnesaemia 133 hypernatraemia 129–30 hyperosmolar hyperglycaemic state 142–4 hyperosmolar non-ketotic coma 143 hyperphosphataemia 132 hypertension crises 101–2 emergencies 102–3 encephalopathy 101 ICU admission 101 intra-abdominal 181, 182t malignant 101 pregnancy-induced 354 hyperthermia 320–3 hyperventilation 203t hypno-sedative toxidrome 331t hypocalcaemia 133–4 hypodynamic shock 65 hypoglycaemia 139 hypokalaemia 130–1 hypomagnesaemia 132–3 hyponatraemia 127–9 hypophosphataemia 132 hypotension permissive 300 severe sepsis 246 spinal cord injury 307 hypothalamic–pituitary–adrenal axis 148–9 Index 457 hypothalamic–pituitary–thyroid axis 145–6 hypothermia 324–5 post-cardiac surgery 430 therapeutic 106–8 hypovolaemic shock 64 hypoxaemia 1–5, 57, 58 hypoxaemic hypoxia hypoxia 1, hypoxic respiratory drive 7, 10 I I:E ratio 15t imidazoles 243 imipenem 235–6 immune-enhancing nutrition 186 immune reconstitution inflammatory syndrome (IRIS) 259–60 immunocompromised 53 immunosuppression 164 Impella 88t incremental PEEP 21 Independent Mental Capacity Advocate 413, 415 induced emesis 329 infection biomarkers 229–30 burns 317 catheter-related blood stream 268–71 central nervous systems 223–8 control 231 definition 246 diarrhoea 175–6 failure to respond to treatment 230–1 metastatic in pneumonia 55 multidrug-resistant organisms 266–8 nosocomial 265–74 risk factors in critical illness 229 inferior vena cava diameter 75 filters 58 influenza 255–6 inhalation injury 44–5 inhaled nitric oxide 43t Injury Severity Score (ISS) 394 inotropes 79–85, 105 inspiration 15t inspiration time 15t insulin 83t high dose therapy 341–2 Intensive Care National Audit and Research Centre (ICNARC) 397 intensive care unit (ICU) bed space 385–6 calculated capacity 385 design 385–6 discharge from 407–10 history of intensive care medicine 383 levels of care 384 nurse to patient ratio 386–7 open and closed units 384–5 performance indicators 396–7 side rooms 386 staffing 386–8 inter-hospital transfer 398 intermittent haemodialysis 124 intra-abdominal hypertension 181, 182t intra-abdominal pressure 181 intra-aortic balloon pump 85–7 intracerebral haemorrhage 211–12 intracranial bolts 201, 204 intracranial pressure consequences of raised pressure 199 determinants 196–7 lumbar puncture 224 management of raised pressure 203t manipulation 202–3 monitoring 201 waveform 201, 202f, 202t intracranial surgery 437–9 intra-hospital transfer 398 intraparenchymal transducer (bolt) 201, 204 intra-unit transfer 398 intravenous immunoglobulin 255 intravenous iodinated contrast 115 intrinsic PEEP 48 intubation 28 failed 30–1 iodinated contrast 115 ipratropium bromide 47t iron toxicity 339–40 ischaemia–reperfusion injury 429–30 ischaemia time 375 ischaemic stroke 209–10 itraconazole 243 J jejunal feeding 185 jugular venous bub oximetry 204 K ketamine 191t ketoconazole 243 key papers 445–50 key quality indicators 396 Kidney Disease Improving Global Outcome (KDIGO) 112 King’s College criteria 155, 156t Kocher’s point 214 L labetolol 102t labour on ICU 351 lactate 66 lactic acidosis 66, 67t 458 Index large bowel GI haemorrhage 173–4 L-arginine 186 lasting power of attorney 415 left-sided heart failure 103 left ventricular end diastolic volume 74, 75f legal issues advanced directives 414–15 capacity, competence and consent 412–14 deprivation of liberty 415–16 frameworks 411–12 lasting power of attorney 415 Legionella 55–6 levels of care 384 levofloxacin 238 levosimendan 79, 82t, 105 LiDCO 71–2 Light’s criteria 59 lincosamides 240–1 linezolid 241 lipopolysaccharides 265 lithium poisoning 343–4 liver disease coagulopathy 289 renal protection 116 see also acute liver failure; chronic liver failure/cirrhosis liver transplantation 163–5 emergency 155, 156t locked-in syndrome 194t lorazepam 191t lower gastrointestinal bleeding 173–4 low molecular weight heparin 58, 125 low T3 syndrome 146 lumbar puncture 223–4 Lundberg waves 201, 202t lung compliance curve 11f lung injury score 12 M Maastricht classification 378t macrolides 236–7, 363 magnesium sulphate 47t, 95t magnetic resonance imaging 311–12 major haemorrhage 280–2 major trauma 297–301 malaria 256–8 malignant hypertension 101 mannitol 203t massive haemoptysis 61–2 massive transfusion 281 maternal cardiac arrest 351–2 maternal death 352–4 mechanical cardiovascular support 85–8, 105 mechanical ventilation adverse effects 17 airway pressure release 24 ARDS patients 42t asthma 48–9t cardiovascular support 85 CO2 clearance 17 COPD 50 dead space dynamic hyperinflation 48 failure to wean 35–6t heart failure 105 high-frequency oscillatory 22–4 intracranial surgery 438 invasive 20 mandatory modes 16 modes 15–16 neutrally adjusted ventilatory assist 17t, 24–5 non-invasive 18, 19t oxygenation 17 PEEP titration 20–1 pneumonia management 55 pressure controlled 16t pressure regulated volume control 16t pressure support 17t principles 15–17 prone positioning 21–2 recruitment manoeuvres 20–1 spontaneous modes 16, 17t terminology 15t titration 32 ventilator-associated pneumonia 51–2, 271–4 ventilator-induced lung injury 17 volume assist 17t volume controlled 16t weaning 32–6 medical staff 387 MELD score 157, 158b membrane potential 88–9 meningitis 225–7 meropenem 236 metabolic acidosis 136–7 metaraminol 83t methanol poisoning 336–7 methicillin-resistant Staphylococcus aureus 267 metronidazole 238–9, 363 micafungin 244 micoconazole 243 micro-dialysis catheter 205 midazolam 191t Miller–Fisher syndrome 262 milrinone 82t minimally conscious state 195t minute ventilation 7, 8f, 9f minute volume mixed venous oxygen saturation 66 Model for End-stage Liver Disease (MELD) score 157, 158b MODS 395 Index 459 monitoring carbon dioxide 13 cardiac output 69–73 cardiovascular 65–78 delayed cerebral ischaemia 215t flaps 440 intracranial pressure 201 oxygen 12 post-intracranial surgery 439 respiratory 12–13 status epilepticus 208 traumatic brain injury 204–5 Monro–Kellie doctrine 196–7 morphine 192t mortality, see death MRI 311–12 MRSA 267 multidrug-resistant organisms 266–8 multi-organ dysfunction syndrome 247 Multiple Organ Dysfunction Score (MODS) 395 multiple parameter track and trigger systems 389 Murray score 12 myasthenia gravis 217–18 myasthenic crisis 218 myocardial infarction 98–100 myxoedema coma 147–8 N N-acetylcysteine (NAC) 332–3 nasal cannulae 14–15 National Poisons Information Service 327 near infra-red spectroscopy 204 necrotic pancreatitis 180–1 necrotizing fasciitis 263–4 neomycin 237 neonatal death 353 neuraminidase inhibitors 242–3, 256 neurogenic shock 307 neuroleptic malignant syndrome 335–6 neurological death 372–3 neurological monitoring post-intracranial surgery 439 traumatic brain injury 204–5 neuromuscular disorders 216–20 neuro-protective strategy 200t neutrally adjusted ventilatory assist 17t, 24–5 neutropaenic sepsis 294–5 nitric oxide 43t non-invasive ventilation 18, 19t non-ST elevation acute coronary syndromes 100 non-steroidal anti-inflammatory drugs (NSAIDs) 192t non thyroid illness 146 non-variceal GI haemorrhage 165–8, 173t noradrenaline 80t norfloxacin 238 nosocomial infections 265–74 nurse to patient ratio 386–7 nursing staff 386–7 nursing workload scores 395 nutrition 183–7 acute pancreatitis 180 burns 317 daily nutritional requirements 184t early versus late 186 energy requirements 184 enteral 176, 185–6 hepatic encephalopathy 163 immune-enhancing 186 obesity 406 parenteral 185–6 refeeding syndrome 186–7 O obesity 405–7 obstetric haemorrhage 358–60 occupational therapists 388 oesophageal Doppler 72–3 oesophageal varices 170 old age 404–5 omega-3 186 opiates 192t opioid toxidrome 331t opportunistic infections 260–1 organ donation 374–82 after brain death 377–8 after circulatory death 378–9 conversations about 381–2 end-of-life care and 380–2 eyes 379–80 families and 376–7, 379, 380–2 perinatal 354 tissues 354, 379–80 organ-specific scores 395–6 oseltamivir 242, 256 osmolality 143 outcome acute kidney injury 111 traumatic brain injury 205 oxazolidinones 241 oxygenation index 12 oxygenation scores 12 oxygen cascade 1, 2f, 3–4t oxygen delivery (DO2) 6, 64 oxygen monitoring 12 oxygen therapy 14–15 oxyhaemoglobin dissociation curve 5f P pacemaker action potential 89 pacemaker codes 97t pacing 96–8 460 Index paediatrics 403–4 palliative care 368–70 pancreatitis 177–81 paracentesis 161–2 paracetamol 192t poisoning 331–3 paralytic ileus 308–9 parapneumonic effusion 55 paraquat poisoning 339 parenteral nutrition 185–6 Parkland formula 316 patient-centred decision-making 418 patient diary 409 peak pressure 15t PEEP 15t incremental 21 intrinsic (auto) 48 titration 20–1 penicillins 234–5 peramivir 242 percutaneous coronary intervention 99 percutaneous tracheostomy 38–9 performance indicators 396–7 pericardial tamponade 430, 431, 434t pericarditis 430 perioperative care 423–8 aortic surgery 435–7 cardiac surgery 428–32, 433–4t enhanced recovery after surgery 427–8 free flap surgery 440–1 haemodynamic optimization 426–7 high-risk surgical patients 423–4 intracranial surgery 437–9 pneumonectomy 441–3 surgical risk prediction 424–5 peripartum cardiomyopathy 364 peritoneal dialysis 123 permanent pacing 96t permissive hypotension 300 persistent vegetative state 194t P:F ratio 12 pH 135, 136 pharmacists 387 physiological dead space 6–7 physiotherapists 387 PiCCO 71–2 piperacillin 234–5 placental abruption 359 placenta praevia 359–60 plain X-ray 301, 311 plasma component transfusion 288 plateau pressure 15t platelets disorders of function 286 point-of-care testing 286 transfusion 283, 284t pleural effusions 59–60 pleural fluid analysis 59 Pneumocystis jiroveci 260 pneumonectomy 441–3 pneumonia 51–6 assessment 53 community-acquired 51, 53, 55 complications 55–6 healthcare associated 53 hospital acquired 51 immunocompromised 53 management 55 severity score 53 ventilator-associated 51–2, 271–4 pneumothorax 60 point-of-care systems 286, 290–1 poisoning alcohols 336–7 beta blockers 340–2 calcium channel antagonists 340–2 carbon monoxide 45, 338–9 cyanide 45, 337–8 digoxin 342–3 iron 339–40 lithium 343–4 management principles 327–30 National Poisons Information Service 327 paracetamol 331–3 paraquat 339 salicylates 333 serotonergic agents 334–5, 336t toxidromes 330–1t tricyclic anti-depressants 333–4 polyenes 244 Portsmouth Physiological and Operative Severity Score for the Enumeration of Morbidity and Mortality (P-POSSUM) 424 positive end expiratory pressure (PEEP) 15t incremental 21 intrinsic (auto) 48 titration 20–1 post-anaesthetic care unit (PACU) 426–7 post-cardiac arrest syndrome 106 posterior cord syndrome 304 post-intensive care syndrome 407–9 post-operative care aortic surgery 436–7 cardiac surgery 431–2 free flap surgery 440 intracranial surgery 438 pneumonectomy 442 postpartum haemorrhage 360 post-pneumonectomy syndrome 442 P-POSSUM 424 pre-eclampsia 354–8 pregabalin 192t Index 461 pregnancy anatomical and physiological changes 347–9 antibiotics in 363 cardiac disease 363–4 eclampsia 354–8 ectopic 358–9 foetal assessment 350 high-risk 349 hypertension 354 incidental critical illness 362–5 in intensive care 350–1 pre-eclampsia 354–8 sepsis 362–3 trauma 365–6 pre-hospital transfer 398 preload responsiveness 73–7 pressure adjusted heart rate 395 pressure controlled ventilation 16t pressure regulated volume control 16t pressure support 17t primary survey 298–9 procalcitonin 230 prognostication 108, 109t prolonged QT interval 91 prone positioning 21–2 propofol 191t propofol infusion syndrome 344 prostaglandins 126 Pseudomonas aeruginosa 268 pulmonary artery catheter 69–71 pulmonary embolus 56–9 pulse contour analysis 71–2 pulse oximetry 12 Q QT prolongation 91 quality control 396 quinine 257 quinolones 238, 363 R raised intracranial pressure consequences 199 lumbar puncture 224 management 203t ramp-down and ramp-up systems 390 Ranson score 178–9 rapid sequence induction 28–9 rapid shallow breathing index 34 ‘reasonable patient’ test 414 receiver operator curve 392 recombinant factor VII 282 recruitment manoeuvres 20–1 red cell transfusion 276–9 red man syndrome 240 refeeding syndrome 186–7 rehabilitation 409 relative adrenal insufficiency 149 remifentanil 192t renal replacement therapy 121–7 access 122 acute kidney injury 118 anticoagulation 125–6 components 121 continuous 123–4 discontinuation 126 haemodiafiltration 122 haemodialysis 121–2 haemofiltration 121 indications 122–3 intermittent haemodialysis 124 membranes 122 modalities 123–5 peritoneal dialysis 123 poisoning 330 slow continuous ultrafiltration 125 slow low efficiency dialysis 125 reperfusion therapy 99, 209–10 reservoir bag mask 14 respiratory monitoring 12–13 respiratory pathophysiology 1–11 respiratory support 14–27 resuscitation decisions 416–17 rewarming 325 rhabdomyolysis 116 Richmond Agitation–Sedation Score (RASS) 190 RIFLE criteria 111, 112f right-sided heart failure 103 rise time 15t risk prediction 424–5 road transport 402t Rockall Score 167 R on T phenomenon 91 rotational thromboelastrometry (ROTEM®) 290, 291t Royal College of Surgeons’ clinical criteria for major gastrointestinal and vascular surgery 424 rule of nines 315 S salbutamol 47t, 50t salicylate poisoning 333 saline, hypertonic 203t SAPS 394 scoring systems 391–8 admission 392–4 disease-specific 395–6 ICU performance 396–7 nursing workload 395 organ-specific 395–6 severity of illness 394–5 462 Index secondary survey 299 second-degree heart block 91 sedation 189–92 adverse effects 189 holds 189–90 scoring systems 190 sedative agents 190–2 seizures 203–4, 206–9 selective digestive decontamination 273–4 selective oral decontamination 273–4 Sengstaken–Blakemore tube 171 senile emphysema 404 sensing threshold 97–8 sepsis 245–55 activated protein C 253–4 beta blockade 254 definitions 245–7 extracorporeal clearance therapy 254 fluid therapy 249–52 goal-directed therapy 249 heparin 254 intravenous immunoglobulin 255 liver transplantation 165 neutropaenic 294–5 pregnancy 362–3 severe 246, 247–8 statins 254 steroids 252–3 Surviving Sepsis Guidelines 247–8 target blood pressure 249 therapy 249–55 septic shock 246, 247–8 Sequential Organ Failure Assessment (SOFA) 394–5 serotonin syndrome 331t, 334–5, 336t severe sepsis 246, 247–8 severity of illness scores 394–5 shock 63–5 cardiogenic 65 distributive (vasodilatory) 65 hyperdynamic 65 hypodynamic 65 hypovolaemic 64 neurogenic 307 pulmonary embolus 58 septic 246, 247–8 spinal 305 short Synacthen test 149 shunt 2 sick euthyroid state 146 sickle cell disease 292–3 side rooms 386 Siggaard–Anderson approach 136–7 sigh breath 21 Simplified Acute Physiology Score (SAPS) 394 single parameter track and trigger systems 389 16s test 230 slow continuous ultrafiltration 125 slow low efficiency dialysis 125 small bowel GI haemorrhage 173–4 SMARTCOP 54f sniff test 75 sodium (corrected) 142 sodium nitroprusside 102t sodium thiosulphate 338 SOFA 394–5 somatic death 372 speech and language therapists 388 spinal clearance 312 spinal cord injury 302–14 airway 306–7, 310–11 autonomic dysreflexia 308 classification 304–5 clearing the spine 312 imaging 311–12 longer term care 314 management 310–14 medical therapy 313 neurological level 305–6 non-traumatic 302–3 paralytic ileus 308–9 pathophysiology 305–10 spinal protection 312–13 surgical interventions 313 transportation 310 traumatic 303–4 spinal drain 437 spinal protection 312–13 spinal shock 305 spontaneous breathing trial 34, 35b staffing 386–8 stagnant hypoxia standard base excess 136 standardized mortality ratio 396–7 Staphylococcus aureus, methicillin-resistant 267 Starling curve 75f static compliance 10 statins 43t, 254 status epilepticus 206–8 ST elevation myocardial infarction 99 Stenotrophomonas maltophila 268 steroids ARDS 43t asthma 47t CIRCI 149–50 COPD 50t critical illness 150 meningitis 227 pneumonia 55 sepsis 252–3 Stewart approach 137–8 Stewart–Hamilton equation 71 Index 463 straight leg raise 75 stress response 148–9 stress ulceration 168–9 stridor, post-extubation 36–7 stroke 209–10 strong ion difference 138 subarachnoid haemorrhage 212–16 surfactant 43t surgical clipping 214t surgical risk prediction 424–5 Surviving Sepsis Guidelines 247–8 sustained inflation 21 Swiss Staging System 324 sympathomimetic toxidrome 331t syndrome of inappropriate antidiuretic hormone secretion 128 systemic inflammatory response syndrome (SIRS) 245–6, 430 T tachyarrhythmia 92, 94t tamponade 430, 431, 434t tandem heart 88t targeted temperature management 106–8 teicoplanin 240 temperature control 320 temporary pacing 97–8 Tensilon test 217 terbutaline 47t terlipressin 160, 171 tertiary survey 299 tetanus 262–3 tetracyclines 363 theophylline 47t therapeutic hypothermia 106–8 Therapeutic Intervention Scoring System (TISS) 395 thermodilution method 71 thermoregulation 320 thiopental 191t third-degree heart block 91 thoracic aortic aneurysm repair 435 three-column theory 313 thrombocytopenia 282–7 thromboelastrograph (TEG) 290, 291f, 291t thrombolysis contraindications 99t pulmonary embolus 58 thrombotic thrombocytopenic purpura 284–5 thyroid axis 145–8 thyroid storm 146–7 tidal volume 15t time constants 11 TIPSS 172 TISS 395 tissue donation 354, 379–80 tissue plasminogen activator 209 tobramycin 237 tocolysis 351 topical oropharyngeal antiseptic agents 273 torsades-de-pointes 91 toxic megacolon 175 toxidromes 330–1t toxin-producing bacteria 264–5 Toxoplasmosis gondii 261 tracheostomy 37–9 track and trigger 389 tranexamic acid 282 trans-cranial Doppler 204 transcutaneous pacing 96t transfer of patients 398–403 transfusion massive 281 plasma components 288 platelets 283, 284t red cell 276–9 transfusion associated cardiac overload (TACO) 278 transfusion-related acute lung injury (TRALI) 278 transjugular intrahepatic porto-systemic shunt (TIPSS) 172 transplantation, liver 163–5 emergency 155, 156t transport modes 401–2 trans-pulmonary dilution monitors 71–2 transudates 59–60 trans-urethral resection of prostate (TURP) syndrome 344–5 transvenous pacing 96t trauma major 297–301 pregnancy 365–6 spinal cord 303–4 traumatic brain injury 195–206 classification 195 general management 199–200 mechanisms and physiology 196–9 neurological monitoring 204–5 neuro-protective strategy 200t neurosurgical referral 200b outcome prediction 205 polyuria 205–6 prevention of secondary injury 200–4 primary 196 secondary 196 seizures 203–4 triazoles 243 tricyclic anti-depressant poisoning 333–4 trimethoprim 363 Trojan horse hypothesis 153 tumour lysis syndrome 116, 295 TURP syndrome 344–5 464 Index U ultrasound major trauma 301 oesophageal Doppler 72–3 renal tract 118 trans-cranial Doppler 204 unfractionated heparin 58, 125 upper gastrointestinal haemorrhage non-variceal 165–8, 173t stress ulceration 168–9 variceal 170–2, 173t uraemia 286 V valgancyclovir 242 vancomycin 240 vancomycin-resistant Enterococcus 267 variceal haemorrhage 170–2, 173t vasodilatory shock 65 vasopressin 84t vasopressors 79–85 vasospasm 214–15 Vaughn–Williams classification 94, 95t venous-arterial extracorporeal membrane oxygenation 88t venous oxygen saturation 66 ventilation 6 alveolar 6–7 mechanics of 10–11 minute 7, 8f, 9f volumes 6, 7f see also mechanical ventilation ventilation/perfusion (V/Q) mismatch ventilator-associated pneumonia 51–2, 271–4 ventilator-induced lung injury 17 Vigileo 72 vitamin B12a 338 volume assist 17t volume controlled ventilation 16t Von Willebrand’s disease 286 voriconazole 243 W Warkentin 4T score 284, 285t warm ischaemia time 375 weakness 216–17 weaning 32–6 West Haven grade 154t whole bowel irrigation 329 whole lung compliance 11 Wolff–Parkinson–White syndrome 91 World Federation of Neurosurgeons, SAH grading 213t written consent 413 Z zanamivir 242 ... R A comparison of albumin and saline for fluid resuscitation in the intensive care unit New England Journal of Medicine 20 04; 350 (22 ): 22 47–56 Guidet B, Martinet O, Boulain T, et al Assessment... Medicine 20 11; 364 (26 ): 24 83–95 Myburgh JA, Finfer S, Bellomo R, et al Hydroxyethyl starch or saline for fluid resuscitation in intensive care New England Journal of Medicine 20 12; 367 (20 ): 1901–11... administered prodrug of gancyclovir 3 .2 Neuraminidase inhibitors 3 .2. 1 General ● ● Includes oseltamivir, zanamivir, and peramivir Indicated in the prevention and treatment of influenza 3 .2. 2 Pharmacokinetics