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General principles of pharmacokinetics and pharmacodynamics

Critically ill patients suffer from a variety of physiologic insults that result in a rapidly changing physiologic status, thus making appropriate drug dosing a challenging problem. Understanding how these changes affect pharmacokinetics and pharmacodynamics can result in improved dosing decisions. This chapter reviews the basic principles of pharmacokinetics and pharmacodynamics and how they may be affected by critical illness. The terms pharmacokinetics and pharmacodynamics describe the…

Diabetes insipidus

Diabetes insipidus is a disorder of water metabolism associated with polyuria, urine hypotonicity, and hypernatremia. , The quantitative criteria include urine output greater than 200 mL/hr or 3 mL/kg/hr, urine osmolality less than 150 mOsm/kg, and plasma sodium greater than 145 mEq If urine osmolality measurement is not available, hypotonicity can be assessed from a urine specific gravity less than 1.005. Central diabetes insipidus Neurogenic or…

Thyroid disorders

Normal thyroid hormone economy Regulation Synthesis and secretion of thyroid hormone is under the control of the anterior pituitary hormone thyrotropin (or thyroid-stimulating hormone [TSH]). Consistent with a classic negative feedback system, TSH secretion increases when serum thyroid hormone levels fall and decreases when they rise ( Fig. 137.1 ). TSH secretion is also under the regulation of the hypothalamic hormone thyrotropin-releasing hormone (TRH). The negative…

Adrenal insufficiency

During stress response, the central nervous system (CNS) induces activation of both the sympathoadrenergic system (by release of catecholamines) and the hypothalamic-pituitary-adrenal (HPA) axis (by release of steroid hormones, glucocorticoids [GCs], and mineralocorticoids), with the target of maintaining homeostasis by influencing metabolic, cardiovascular, immunologic, and endocrine functions. In this context, the adrenal gland plays a key role, combining the location for synthesis and expression of catecholamines,…

Diabetic ketoacidosis and hyperosmolar hyperglycemic state

Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are endocrine emergencies occurring in diabetes patients. Both conditions require prompt, adequate treatment to avoid mortality. In patients with known diabetes mellitus, both conditions are most commonly triggered by noncompliance with diabetes treatment or infection. Nevertheless, any condition that induces severe insulin resistance and elevated counterregulatory hormones may trigger DKA or HHS, including severe trauma, myocardial infarction, and…

Postpartum hemorrhage

Obstetric hemorrhage remains a leading cause of maternal mortality and morbidity worldwide, with most deaths occurring in the postpartum period. Recognition of blood loss in obstetric hemorrhage can be challenging. Therefore interventions focused at the patient level, provider and unit level, and system level are imperative in order to provide optimal patient care. In smaller centers, guidelines to establish which patients should be triaged to a…

Acute pulmonary complications during pregnancy

During pregnancy, the respiratory system undergoes a number of changes and is subject to functional and anatomic stresses. The critical care provider must remember these changes to appropriately care for the maternal-fetal unit. Although the need for ventilatory support is rare in pregnancy, respiratory insufficiency, which may complicate up to 1 in 500 pregnancies, is still the most common indication in pregnancy for admission to a…

Hypertensive disorders in pregnancy

Hypertensive disorders associated with pregnancy are the most common medical diagnoses in pregnancy, occurring in approximately 6%–8% of pregnancies. , Guidelines from the Society of Obstetricians and Gynecologists have classified hypertension of pregnancy into two categories: (1) preexisting chronic hypertension or (2) preeclampsia superimposed on either gestational hypertension or preexisting chronic hypertension. The National High Blood Pressure Education Working Group on High Blood Pressure in Pregnancy…

Cardiovascular and endocrinologic changes associated with pregnancy

Fundamental to the management of a critically ill pregnant woman is a detailed knowledge of the normal physiologic changes that occur during gestation and immediately after delivery. Some of these physiologic adaptations are from the hormonal changes associated with pregnancy, and others are to support the mother and the growing fetus. Clinicians must have a good understanding of the extent of these changes, which occur in…

Critical care of the hematopoietic stem cell transplant recipient

Hematopoietic stem cell transplantation (HSCT) is used to treat an ever-increasing array of disorders, including hematologic and lymphoid cancers; selected solid tumors; and nonneoplastic diseases, including autoimmune disorders, amyloidosis, and aplastic anemia. The main indications for autologous transplantation include multiple myeloma and lymphomas. Allogeneic transplants are most commonly performed for acute and chronic leukemia, lymphoma, and myelodysplastic syndrome. The most common graft source is peripheral blood;…

Monitoring of coagulation status

Overview of effective coagulation Components of hemostasis Fig. 129.1 depicts an overview of hemostasis. In a normal physiologic state, the body maintains a fine balance between hemorrhage and thrombosis through the regulation of various anticoagulant and prothrombotic systems. Four primary factors contribute to normal hemostasis. These factors are the vascular endothelium, platelets, coagulation factors, and fibrinolytic system. The vascular endothelium is capable of evoking both antithrombotic…

Anticoagulation in the intensive care unit

Introduction Patients in an intensive care unit (ICU) often have received or require anticoagulation for multiple reasons that include acute thrombotic issues, mechanical valves, venous thromboembolic prophylaxis, atrial fibrillation, ischemic cardiovascular disease, and/or extracorporeal life support. The types of anticoagulation and need for therapy vary depending on whether patients have arterial or venous thromboembolic issues. These issues are important in critically ill patients and have critical…

Venous thromboembolism

Introduction Venous thromboembolism (VTE), which includes both deep vein thrombosis (DVT) and pulmonary embolism (PE), is a source of significant morbidity and mortality for the critically ill patient. The development of DVT alone in the intensive care unit (ICU) is associated with a longer length of stay, more ventilator days, and an increased mortality rate compared with similar patients without DVT. The annual costs for VTE…

Guidelines for blood component therapy

Blood component therapy is generally supportive for the correction of one or more hematologic deficiencies until the basic disease process can be controlled or corrected. Anemia is pervasive in the intensive care unit (ICU), with over 30%–50% of critically ill patients receiving a transfusion during their ICU stay. Transfusions do not come without risk, and thus the past decade has seen a drastic shift from a…

Anemia and RBC transfusion

Anemia remains common in the critical care population, and its etiology is multifactorial, related to hemorrhage, hemodilution, diagnostic phlebotomy, acute inflammation, and functional iron deficiency. These factors result in decreased red blood cell (RBC) production and reduced RBC survival. This chapter will explore the problem of anemia in the critically ill patient, its causes and effects, and the use and risk of RBC transfusions in the…

Clostridioides difficile infection

Introduction Clostridioides difficile is an anaerobic, spore-forming, gram-positive bacillus that may be part of the normal intestinal microbiota in healthy babies. It was officially renamed in 2016 to Clostridioides difficile. The new name reflects the taxonomic differences between this species and other members of the Clostridium genus. It is spread via the oral-fecal route, and in hospitalized patients may be acquired through the ingestion of spores…

Malaria and other tropical infections in the intensive care unit

Malaria infections are classified broadly into three clinical categories: (1) asymptomatic parasitemia, which generally does not require treatment for those living in endemic areas; (2) uncomplicated malaria, defined as parasitemia (typically low, though perhaps elevated in those who are semi-immune or immune) and fever without evidence of end-organ damage or other signs of severe disease (these patients may often be treated as outpatients with oral antimalarials);…

Tuberculosis

Epidemiology The World Health Organization (WHO) estimates that 1.7 billion people are latently infected with Mycobacterium tuberculosis worldwide . Approximately 10 million active tuberculosis (TB) cases emerge annually, resulting in 1.2 million deaths and making TB the leading cause of death by an infectious agent worldwide. The majority of TB cases occurs in the developing world, with nearly 90% of cases emerging from 30 countries with…

Infections in the immunocompromised patient

Many immunocompromised patients are managed in intensive care units (ICUs) every year, with infection being a leading cause of ICU admission. Common examples of such infections include community-acquired pneumonia, bacteremia, and central nervous system (CNS) infections. The incidence of infections acquired by immunocompromised patients during ICU admissions is also significant. Mortality from certain infections in immunocompromised patients exceeds 50%. Early diagnosis, initiation of appropriate antimicrobial and…

Human immunodeficiency virus infection

Introduction The burden of human immunodeficiency virus (HIV) infection remains a global public health issue, with an estimated 1.8 million new infections and almost 800,000 acquired immunodeficiency syndrome (AIDS)–related deaths in 2018. Around 38 million people are currently living with HIV worldwide (including 8 million patients not aware of their seropositive status), corresponding to a ∼50% increase over the past two decades that reflects both the…