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Intensive care unit imaging

Recent advances in ICU imaging Modern advancements in imaging modalities continue to provide an ever-increasing amount of diagnostic and interventional capabilities to aid in the care of critically ill patients. Continued advancement of bedside ultrasound (US) technology and training has allowed for a drastic increase in the availability and ease of performance of these examinations. As a result, guided bedside procedures, including central venous catheter (CVC)…

Adjunctive respiratory therapy

Many critically ill patients are unable to effectively clear secretions that accumulate in the central and peripheral airways. This failure can be the result of factors such as increased secretion production, impaired cough reflex, weakness, and pain. An endotracheal tube prevents closure of the glottis and the high expiratory flows necessary for effective coughing, thereby promoting the retention of secretions. In addition, in critically ill patients,…

Weaning from mechanical ventilation

The concept of liberation and extubation Weaning from mechanical ventilation refers to the transition period from total ventilatory support to spontaneous breathing. Approximately 70% of intubated mechanically ventilated patients are extubated after the first spontaneous breathing trial (SBT), either by ventilator disconnection or after breathing at low levels of pressure support for short periods ranging from 30 to 120 minutes. , The remaining patients (about 30%)…

Advanced techniques in mechanical ventilation

Introduction Physiologic closed-loop controlled (PCLC) systems run the gamut from simple negative feedback controllers to fully automated control of airway pressure, tidal volume (V T ), minute ventilation (V E ), fraction of inspired oxygen (FiO 2 ), and positive end-expiratory pressure (PEEP). Proposed advantages of PCLC systems include maintenance of evidence-based treatment, rapid response to changes in patient condition, reduced necessity for clinician-machine interaction, and…

Noninvasive positive-pressure ventilation

Noninvasive ventilation is defined as the provision of ventilatory assistance to the lungs without an invasive artificial airway. Noninvasive ventilators consist of a variety of devices, including negative- and positive-pressure units. Until the early 1960s, negative-pressure ventilation in the form of tank ventilators was the most common type of mechanical ventilation used outside the anesthesia suite. However, during the Copenhagen polio epidemic of 1952, it was…

Patient–ventilator interaction

Clinical management of patients with acute respiratory failure is based on the concept that significant changes in respiratory mechanics, respiratory muscle performance, and control of breathing are the underlying mechanisms responsible for acute respiratory failure. The effects of mechanical ventilation on gas exchange, respiratory muscle load, and dyspnea depend on the matching between the ventilator settings and the patient’s respiratory physiology. However, mechanical ventilation is rarely…

Core principles of respiratory physiology and pathophysiology in critical illness

Introduction Understanding physiology underpins the logical decisions of critical care practice. Although facts and knowledge of literature findings and recommendations for specific problems clearly help inform good management, bedrock principles of physiology and pathophysiology translate across patients; awareness of them is a salient trait of the expert clinician. Providing respiratory support is among the defining features of intensive care, and to execute this effectively, an understanding…

Neuroimaging

This chapter reviews available neuroimaging methods and their application in the evaluation and management of the critically ill and injured. Imaging modalities Radiography Plain radiography plays a minor role in evaluating the neurologically ill or injured patient. Radiography is not sensitive for the detection of intracranial pathology and is not part of the standard imaging approach for the evaluation of patients with such pathology. Conventional radiography…

Spinal cord injury

Introduction Despite many advances made in its diagnosis and treatment, spinal cord injury (SCI) continues to present challenging critical care issues to be treated, both acutely and chronically. The injury undoubtedly results in substantial psychological and financial impact not only on patients and their families but also to the general society. To date, the basis of care for patients with SCI has primarily focused on providing…

Traumatic brain injury

Introduction Traumatic brain injury (TBI) is a medical and social problem worldwide, with an estimated 10 million cases leading to hospitalization or death each year. Most TBIs are mild, and the incidence of TBI varies widely by ages and between countries. In the United States, trauma is the leading cause of death in individuals aged 1–45 years old, and TBI accounts for the majority of these,…

Neuromuscular disorders in the critically ill

Abnormal neuromuscular function may precipitate a patient’s admission to an intensive care unit (ICU) or it may develop because of another critical illness and its treatment. This chapter focuses primarily on respiratory failure caused by neuromuscular disease but also addresses autonomic dysfunction that occurs in this setting. A brief review of the motor unit and its physiology is provided to facilitate understanding of the concepts involved,…

Seizures in the critically ill

Introduction The routine use of continuous electroencephalographic (cEEG) recordings in intensive care demonstrates that clinical seizures in critically ill patients, both with neurologic and nonneurologic conditions, are the tip of the iceberg regarding seizure frequency in this vulnerable population. Nonconvulsive seizures are detected in 10%–30% of critically ill patients with altered mental status and in up to 60% of critically ill patients who have been witnessed…

Nontraumatic intracerebral and subarachnoid hemorrhage

Hemorrhage Epidemiology Intracerebral hemorrhage (ICH) is the second most common type of stroke, following only ischemic stroke in frequency. Spontaneous, nontraumatic ICH accounts for approximately 9%–27% of all strokes globally. , The incidence doubles every decade after age 35. , Outcomes are typically poor, with a mortality of 50% at 30 days. A systematic review in 2013 found that the burden of death and disability is…

Management of acute ischemic stroke

Stroke is currently recognized as the fifth most common cause of death and the leading cause of permanent disability in the United States, affecting nearly 795,000 people annually. Acute ischemic stroke is a true medical emergency and must be treated with a swift yet pragmatic approach. The rationale for acute ischemic stroke treatment is based on the concept of the ischemic penumbra . When arterial occlusion…

Cardiopulmonary cerebral resuscitation

Cardiopulmonary arrest occurs as the endpoint or consequence of many diseases. The mechanism is often unknown when treatment is initiated, and an algorithmic approach titrated to real-time monitoring is used. When the cause is known or suspected, individualized therapy can be directed at that cause. In all cases, management has two priorities: (1) rapid restoration of cardiopulmonary function and (2) minimization of ischemic damage to end…

Use of brain injury biomarkers in critical care settings

Brain injury represents a constellation of both well- and ill-defined neurologic conditions that are the sequelae of both traumatic and nontraumatic illness, including stroke, anoxic-ischemic events, and sepsis. Traditionally, computed tomography (CT), magnetic resonance imaging (MRI), and electroencephalography (EEG) have been the diagnostic standards for differentiating brain injury from other forms of encephalopathy. In addition, these studies have been used as adjuncts to the clinical assessment…

Coma

Coma Disorders of altered consciousness present a diagnostic dilemma to the clinician in the critical care setting. They represent a wide of range of pathology that can be systemic in nature or the result of structural or nonstructural intracranial pathology. Immediate evaluation and accurate diagnosis leading to lifesaving interventions are of paramount importance, as some causes of coma are irreversible. However, this can be a difficult…

Advanced bedside neuromonitoring

Introduction Little can be done to reverse the primary brain damage caused by an insult; however, one of the major factors influencing outcome in patients with acute brain injury is the additional brain damage that occurs from secondary brain injury processes. These secondary insult processes entail a combination of inflammatory, biochemical, and excitotoxic changes, , making it challenging for the clinician to detect which processes are…

Nutritional support

Critically ill patients typically have anorexia and are frequently unable to take oral diets. Therefore micronutrients and macronutrients should be prescribed as enteral or parenteral nutrition. The catabolic response of critical illness is characterized by inflammatory and endocrine stress responses that may induce variations in resting energy expenditure (REE) and urinary nitrogen excretion. Nutritional intake may be insufficient and lead to accumulated energy and protein deficits.…

Extracorporeal membrane oxygenation (venovenous and venoarterial ECMO)

Introduction Use of extracorporeal life support (ECLS) for respiratory and/or cardiac failure continues to increase, with almost 500 Extracorporeal Life Support Organization (ELSO) centers worldwide and almost 100,000 patients now added to the ELSO registry. In actuality, ECLS use is likely much higher, as many centers do not report data to ELSO or any other international registry. The survival rate for ECLS varies significantly by indication…