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Tracheostomy

Indications Airway access for the treatment of upper airway obstruction or mechanical ventilation (MV) can be obtained by either orotracheal intubation (OTI) or placement of a tracheostomy tube. During general anesthesia or after episodes of acute respiratory failure, patients are usually mechanically ventilated through an orotracheal tube, which can be easily and rapidly inserted as an initial airway device. When prolonged MV is provided or protection…

Tracheal intubation

Introduction Tracheal intubation is a commonly performed, high-risk procedure in critically ill patients. There are important differences between elective intubation in the operating room compared with emergency intubation in the intensive care unit (ICU). Risks associated with emergent intubation in the critically ill include hypoxemia, hemodynamic instability, cardiac arrest, and death, underlining the importance of a systematic approach to optimize physiologic conditions and maximize first-attempt success.…

Arterial blood gas interpretation

Although arterial blood gas (ABG) data provide critical information to the practitioners of critical care medicine, ABG analysis is among the most frequently ordered test in the intensive care unit (ICU), is overused, and is associated with burdens to our patients (discomfort, blood loss) and healthcare systems. Therefore appropriate understanding and use of this clinical test is important for optimal care. There are no randomized trials…

Bedside monitoring of pulmonary function

Pulse oximetry Pulse oximetry is a microprocessor-based measurement that incorporates both oximetry and plethysmography to provide continuous noninvasive monitoring of the oxygen saturation of arterial blood (SpO 2 ). Often considered the “fifth vital sign,” pulse oximetry is one of the most important technologic advances for monitoring patients during anesthesia, in the intensive care unit (ICU), on the general ward, in the emergency department, and during…

Cardiovascular monitoring

Introduction Over the last decades, cardiovascular monitoring techniques used in the intensive care unit (ICU) and operating room (OR) have progressively evolved from invasive toward less invasive approaches. In the 1990s, the pulmonary artery catheter (PAC) was at its apogee, as it was the only method to assess and monitor hemodynamics at the bedside. The PAC has provided clinicians with measurements of cardiac output (CO), pulmonary…

Echocardiography

Over the past 60 years, echocardiography has undergone substantial developments to become one of the most common modalities in the field of cardiovascular imaging. Starting in the 1980s, technologic advancements and the recognition of its potential moved echocardiographic imaging quickly into the operating room, emergency room, and intensive care unit (ICU). Today, it is fully integrated into medical subspecialties, such as anesthesiology, emergency medicine, critical care,…

Point-of-care ultrasound

Recent advances in ultrasound technology have allowed ultrasound instruments to become smaller, more portable, and less expensive, so that this powerful imaging tool can be readily and repeatedly used in everyday intensive care unit (ICU) care. The concept of point-of-care ultrasound (POCUS) refers to the use of portable ultrasonography at the patient’s bedside for diagnostic and therapeutic purposes. The provider acquires and interprets all images in…

Biochemical or electrocardiographic evidence of acute myocardial injury

The identification of myocardial injury is an important problem in the critical care setting. Biomarkers have been used to detect myocardial injury since 1954. Since then, the sensitivity of serologic techniques has increased dramatically. Although increased sensitivity has allowed clinicians to detect smaller amounts of myocardial necrosis, this has also posed several interpretive challenges. What constitutes significant myocardial damage? How should evidence of myocardial necrosis be…

Chest pain

Initial approach Several life-threatening conditions can cause chest pain in the critically ill, and the initial approach should focus on prompt evaluation and resuscitation of the airway, breathing, and circulation. Assess the patient’s level of consciousness, palpate the pulse, and listen to the breath sounds and heart. Obtain vital signs, including oxygen saturation by pulse oximetry, and ensure that the patient is attached to a cardiac…

Diarrhea

Diarrhea is one of the most common manifestations of gastrointestinal (GI) dysfunction in the intensive care unit (ICU); the reported incidence is between 2% and 63%. Diarrhea is best defined as bowel movements that, because of increased frequency, abnormal consistency, or increased volume, cause discomfort to the patient or the caregiver. This definition demonstrates the subjectivity in diagnosing diarrhea, which complicates interpretation of the literature and…

Ileus in critical illness

Introduction Evidence of ileus, gastroparesis, or small bowel dysmotility is common in the setting of critical illness. Data on the incidence of ileus estimate an occurrence ranging from 50% to 80% in critically ill patients, with an average incidence of 38%. In the postoperative surgical intensive care unit (ICU), evidence of postoperative ileus ranges from 24% to 75%. Ileus can affect the entire gastrointestinal (GI) tract…

Acute abdominal pain

Introduction Diagnosing acute abdominal pain in critically ill patients can be difficult if the clinician tries to work through a comprehensive list of differential diagnoses ( Fig. 25.1 ). The most common etiologies seen outside of the intensive care unit (ICU) also occur within it, but other diagnoses must be considered. Certain patient populations to include trauma patients, postoperative patients, and those who are immunosuppressed, to…

Ascites

Definition and diagnosis Whereas a normal peritoneal cavity contains only 25 mL of fluid, the peritoneum has the capacity to absorb 900 mL Ascites is the pathologic accumulation of peritoneal fluid, occurring most commonly in decompensated liver cirrhosis (85%), with malignancy, tuberculosis, heart failure, and pancreatitis accounting for the remainder. , The International Club of Ascites classifies ascites severity, with fluid detectable only on imaging (<100…

Jaundice

Bilirubin is a by-product of heme metabolism. Heme is largely derived from the hemoglobin in senescent red blood cells and is oxidized in the spleen, liver, and other organs by two isoforms of the enzyme heme oxygenase, in the presence of nicotinamide adenine dinucleotide phosphate (NADPH) and molecular oxygen, to form biliverdin, carbon monoxide, and iron. Subsequently, biliverdin is converted into bilirubin by the phosphoprotein biliverdin…

Coagulopathy in the intensive care unit

Divergent patient populations: Trauma versus sepsis Noncardiac intensive care units (ICUs) predominantly manage coagulopathy in patients with trauma or sepsis. Although trauma is known as the third most frequent cause of death in the United States, sepsis, which is not as well categorized, is believed to be the leading cause of death in hospitalized patients. Both patient populations are at risk of developing coagulation abnormalities. However,…

Anemia

Introduction Anemia is defined as a reduction in the circulating red cell mass, the hemoglobin concentration, or both with an associated decrease in the oxygen-carrying capacity of blood. It is among the most common clinical problems encountered among critically ill patients in the intensive care unit (ICU). Although a proportion are anemic on admission, the majority of the remainder become anemic during their ICU stay, and…

Disorders of glucose control or blood glucose disorders

Introduction Alterations in glucose metabolism are common in the intensive care unit (ICU). The adverse effects of uncontrolled hyperglycemia, especially in a critically ill patient, are fairly well described. Management strategies for hyperglycemia in the critically ill patient have gone through substantial changes over the past two decades. Although hyperglycemia is associated with adverse clinical outcomes, trying to achieve euglycemia in all patients has not proven…

Hypocalcemia and hypercalcemia

Abnormal serum calcium concentration is a common finding in critically ill patients. The prevalence of hypocalcemia in intensive care unit (ICU) patients ranges from 70% to 90% when total serum calcium is measured and from 15% to 50% when ionized calcium is measured. Hypercalcemia occurs less frequently, with a reported incidence of <15% in critically ill patients. Hypocalcemia is associated with injury severity and mortality in…

Hypomagnesemia

Magnesium is an important ion that participates as a cofactor in over 300 enzymatic reactions, especially in those involving adenosine triphosphate (ATP). Hypomagnesemia is common in critically ill patients and is associated with increased mortality. , Cellular physiology and metabolism of magnesium Magnesium is a divalent cation (Mg ++ ) that is predominantly localized to the intracellular compartment (99%). It is the second most abundant intracellular…

Hyperphosphatemia and hypophosphatemia

Introduction Disturbances in the phosphate balance are common in critically ill patients, but are not always easy to relate to specific symptoms. Dysphosphatemia, however, may cause a significant increase in multiorgan failure. In a Swedish critical care cohort, more than half of the patients showed at least one serum phosphate concentration value outside the normal range ( Fig. 17.1 ). Serum phosphate levels should be measured…