Physical Address

304 North Cardinal St.
Dorchester Center, MA 02124

Fluid and volume therapy in the ICU

The goals of fluid administration are to optimize tissue oxygenation by augmenting intravascular volume, improving left ventricular preload, and increasing cardiac output. This chapter reviews the timing and considerations for choice of therapy in volume repletion and the effects of fluid volume overload in the postresuscitation period. Timing of initial volume therapy Studies from the early 2000s suggested that earlier recognition and treatment of septic shock…

Advanced techniques in blood purification

Introduction During the last decade, several blood purification techniques have been developed. Blood purification techniques are extracorporeal treatments that can either be combined with renal replacement therapy (RRT) or used as standalone methods. Their common objective is to remove from the blood proteins or cells that may have deleterious effects. These techniques are mostly used in septic shock, targeting endotoxins, cytokines, proinflammatory cells, or even bacteria…

Water metabolism

Water is the body’s most abundant component. Without ingesting sufficient fresh water, humans can survive for just a few days. Ingested water, plus water produced endogenously, must be appropriately excreted to maintain homeostasis. In the human body, water has many functions: intracellular, intravascular, and extracellular carrier of essential substances; body coolant, lubricant, reactant, and product in metabolic reactions; and shock absorber (e.g., cerebrospinal fluid [CSF] surrounding…

Biomarkers of acute kidney injury

Epidemiology of acute kidney injury in the intensive care unit Acute kidney injury (AKI) is a significant problem in intensive care unit (ICU) patients and carries a high mortality rate and long-term morbidity. AKI is defined according to the Kidney Diseases Improving Global Outcomes (KDIGO) criteria, including three alternatively applied components: (1) serum creatinine increase (from baseline of >27 micromol/L or >0.3 mg/dL within a maximum…

Clinical assessment of renal function

Five to fifteen percent of patients in intensive care units (ICUs) experience acute deterioration in renal function. , Renal dysfunction substantially adds to the morbidity and mortality of critically ill patients. Moreover, changes in renal function directly affect drug clearance. Thus a means to assess renal function is essential for the optimal management of patients with critical illness. This chapter reviews selected aspects of renal physiology…

Core principles of renal physiology and pathophysiology in critical illness

Introduction The kidney plays a key role in maintaining solute, water, and acid-base homeostasis. Some or all of these roles may be impaired in critically ill patients because of processes that disrupt glomerular, tubular, or interstitial function. This chapter will cover the core principles of renal physiology and pathophysiology relevant to the intensive care setting. Structures of the nephron The glomerulus The glomerulus is the filtering…

Severe gastrointestinal bleeding

Gastrointestinal bleeding is common, and severe bleeding often requires intensive care unit admission. Optimal management requires hemostatic resuscitation, management of antiplatelet and anticoagulant agents, acid suppression, and a multidisciplinary approach to localization for hemorrhage control, summarized in Fig. 93.1 . Open full size image Fig. 93.1 Severe Gastrointestinal Bleeding Management Algorithm. ACS , Acute coronary syndrome; CT , computed tomography; PCI , percutaneous coronary intervention; PCC…

Toxic megacolon and Ogilvie’s syndrome

Acute megacolon refers to a syndrome defined by abnormal colonic distention in the absence of mechanical obstruction. Megacolon may be a manifestation of Ogilvie’s syndrome or toxic megacolon. The sequelae of these disorders results in diffuse colonic dysmotility. Ogilvie’s syndrome is an eponym for acute colonic pseudo-obstruction (ACPO). , Critical illness–related colonic ileus (CIRCI) is characterized by constipation for several days without marked colonic distention and…

Mechanical bowel obstruction

Mechanical bowel obstruction occurs when there is an occlusion of the lumen of the intestine that causes a blockage of the normal flow of intraluminal contents through the gastrointestinal tract. As a common surgical emergency, 3.2 million cases of bowel obstruction occurred throughout the world in 2015 resulting in 264,000 deaths. , The small bowel is more much frequently affected compared with the large bowel and…

Abdominal sepsis

Introduction Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection and accounts for approximately 20% of deaths worldwide. Despite tremendous advancements in early diagnosis and both surgical and antimicrobial therapies, it remains a leading cause of in-hospital and intensive care unit (ICU) mortality. , Intraabdominal sepsis is the second most prevalent infectious etiology after pneumonia. , Similar to other etiologies…

Acute pancreatitis

Acute pancreatitis is an inflammatory condition of the exocrine pancreas, the severity of which can range from mild edematous changes to severe acute necrotizing pancreatitis. Pancreatitis is one of the most common diseases requiring inpatient hospitalization with an incidence of 34 per 100,000 people worldwide. , In the United States the annual cost associated with treatment of acute pancreatitis has increased by 365% from 1997 to…

Calculous and acalculous cholecystitis

Evaluating the patient with a possible acute abdomen and intraabdominal sepsis in the intensive care unit (ICU) can be challenging. Patients frequently have multiple potential sources of sepsis and are often unable to describe symptoms or localize tenderness on physical examination. In addition, many imaging studies require transporting the patient to the radiology suite, which can be risky. These issues are especially troublesome for patients with…

Acute liver failure

Introduction Acute liver failure (ALF), also known as fulminant hepatic failure, is a compelling example of complex critical illness. The initiating event is extreme liver injury from a variety of possible causes. Thereafter, a severe multisystem critical illness rapidly develops, involving disruption of function in virtually all organ systems ( Fig. 87.1 ). Although ALF is a relatively rare cause of admission to the intensive care…

Hepatic encephalopathy

Hepatic encephalopathy encompasses a spectrum of neuropsychiatric abnormalities that occur in patients with liver disease in the absence of other brain disease. , The spectrum includes personality changes, impaired mental function, motor abnormalities (i.e., asterixis, tremors, hyperventilation, hyperactive reflexes), and altered consciousness. A consensus panel of experts proposed the classification of hepatic encephalopathy into type A, associated with acute liver failure (ALF); type B, associated with…

Hepatopulmonary syndrome

Definition Hepatopulmonary syndrome (HPS) is defined by an abnormally low arterial oxygen level associated with intrapulmonary vascular dilatations (IPVDs) in patients with liver disease. The presence of coexisting cardiopulmonary disease, which may contribute to impaired gas exchange, should be considered but does not exclude this diagnosis. HPS is most commonly associated with cirrhosis and portal hypertension, but neither of these is required for its diagnosis. The…

Hepatorenal syndrome

An association between advanced liver disease, ascites, and renal failure described in 1861 was named hepatorenal syndrome (HRS) by Helvig and Schutz in 1932. Until recently, HRS has been thought of as a purely functional form of renal failure without renal histologic changes. HRS is characterized by intense renal vasoconstriction, impaired renal perfusion, and low glomerular filtration rate (GFR) in the setting of splanchnic and systemic…

Portal hypertension: Critical care considerations

The change of a paradigm Portal hypertension is not the only driver of complications of cirrhosis Cirrhosis is typically classified as compensated or decompensated, based on the absence or presence (or previous history) of variceal bleeding, ascites, jaundice, or encephalopathy. The significantly longer survival—usually symptomless—and better quality of life experienced by patients with compensated cirrhosis compared with those with decompensated cirrhosis have brought about the concept…

Mechanical support in cardiogenic shock

Heart disease remains the leading cause of death in both men and women among African Americans, Hispanics, and Caucasians in the United States, accounting for nearly 650,000 deaths annually. Significant progress has been made over the past few decades in defining and recognizing cardiogenic shock (CS), and although there are many potential causes of this condition, acute myocardial infarction (AMI) with a large loss of functioning…

Inotropic therapy

Rationale for using inotropic therapy in the critically ill Two different objectives for using inotropes in the critically ill have been considered: (1) the attempt to improve cardiac function in patients with low blood flow related to reduced myocardial contractility and (2) the attempt to achieve supranormal values of cardiac output in order to prevent or reduce oxygen debt; in this situation, inotropes might be given…

Resuscitation from circulatory shock

Introduction Shock can be defined as a state of circulatory failure to deliver sufficient oxygen to balance the demands of the tissues, which results in tissue hypoxia: a deficiency in the bioavailability of oxygen to the tissues of the body. Circulatory shock assessment is often a challenging and common clinical scenario (i.e., up to one-third of patients admitted to the intensive care unit [ICU] are in…