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Microbiologic Considerations in the Intensive Care Patient

Objectives This chapter will: 1. Discuss general concepts of common infections in the intensive care unit. 2. Review risk factors and strategies to decrease microbial resistance including antimicrobial stewardship. 3. Discuss particular characteristics pertinent to critically ill patients such as immunosuppression. Epidemiology of Infections in the Intensive Care Unit Serious infections leading to hemodynamic instability are a common cause for admission to the intensive care unit…

Enteral Nutrition

Objectives This chapter will: 1. Describe the benefits that nutritional support can provide in the critically ill. 2. Explain the reasons why enteral nutrition should be preferred. 3. Discuss the risks associated with gastric feeding. 4. Outline three alternative strategies for patients with enteral feeding intolerance. 5. Discuss how to optimize the choice of substrates (particularly glutamine and omega-3 fatty acids) in the composition of enteral…

Blood Glucose Control in Critical Care

Objectives This chapter will: 1. Describe the nature of stress-induced hyperglycemia. 2. Explore the possible significance of normoglycemia in critically ill patients. 3. Discuss the importance of blood glucose control and nutritional support. 4. Describe the risk and incidence of hypoglycemia in relation to pursuing tighter blood glucose control. 5. Review recent recommendations for blood glucose control in critically ill patients. Acute hyperglycemia is common in…

Management of Nutrition in Acute Kidney Injury and Renal Replacement Therapy

Objectives This chapter will: 1. Describe the complex metabolic milieu of critically ill patients with acute kidney injury. 2. Explain the effects of acute kidney injury on the metabolism of nutrients and reveal the nutritional requirements of critically ill patients with acute kidney injury. 3. Outline practical aspects of the management of artificial nutrition in critically ill patients with acute kidney injury. 4. Explain the impact…

Anemia of Critical Illness

Objectives This chapter will: 1. Outline the limitations of current definitions of anemia. 2. Describe the relationship of the anemias of inflammation and critical illness. 3. Review literature outlining the epidemiology of the anemia of critical illness. 4. Outline the proposed mechanisms of the anemia of critical illness. In the past decade, significant advances have been made in our understanding of the anemia found in critically…

Endocrinology of the Stress Response During Critical Illness

Objectives This chapter will: 1. Provide an overview of the stress response. 2. Review changes in the hypothalamic-pituitary-adrenal axis during critical illness. 3. Review stress hyperglycemia. 4. Review stress hyperlactemia. 5. Describe the sick euthyroid/low T3 syndrome. 6. Describe changes in the hypothalamic-pituitary growth hormone axis during critical illness. Stress Response The stress system receives and integrates a diversity of cognitive, emotional, neurosensory, and peripheral somatic…

Carbohydrates and Lipids

Objectives This chapter will: 1. Describe the main alterations in carbohydrate and lipid metabolism in isolated and complicated acute renal failure. 2. Elucidate the mechanisms of carbohydrate and lipid metabolic dysfunctions. 3. Highlight the therapeutic implications of the metabolic alterations. Patients with acute renal failure (ARF) may present with a widely varying hormonal and metabolic status. The isolated acute loss of excretory renal function causes metabolic…

Amino Acid Turnover, Protein Metabolism, and Nitrogen Balance in Acute Kidney Injury

Objectives This chapter will: 1. Discuss the concept, pathogenesis, and impact of protein energy wasting in a patient with critical illness and acute kidney injury. 2. Discuss the significance of muscle wasting in conjunction with protein catabolism early in critical illness. 3. Discuss the effects of acute kidney injury and renal replacement therapy on amino acid and nitrogen balance. 4. Relate these concepts with purported nutritional…

Impact of Renal Replacement Therapy on Metabolism and Nutrient Requirements in the Critically Ill Patient

Objectives This chapter will: 1. Explain the impact of several modalities of renal replacement therapy on metabolism and nutrient balances. 2. Describe the effect of extracorporeal circuits and different types of anticoagulation on the inflammatory state of the patient. 3. Teach how to minimize these side effects and adapt nutrition therapy to compensate therapy-associated changes in nutrient requirements. Renal replacement therapy (RRT) modalities are following a…

Energy Requirement and Consumption in the Critically Ill Patient

Objectives This chapter will: 1. Describe the pathogenesis of hypermetabolism in critical illness. 2. Delineate the components of total energy expenditure. 3. Review techniques for the measurement of energy expenditure in critically ill patients. 4. Explain how to estimate energy expenditure in the critically ill. 5. Highlight the distinction between energy requirement and energy consumption in critical illness. Metabolic Response to Critical Illness In 1932 Cuthbertson…

Iatrogenic and Poison-Derived Acid Base Disorders

Objectives This chapter will: 1. Help the reader understand the significance of acid-base disturbances in the critical care setting. 2. Identify common iatrogenic acid-base disorders in the intensive care unit. 3. Acknowledge common drugs used in clinical practice causing acid-base disorders. 4. Explain the importance of alcohol dehydrogenase inhibition and extracorporeal removal of toxic alcohols in the treatment and prevention of profound metabolic acidosis. 5. Discuss…

Respiratory Acid-Base Disorders

Objectives This chapter will: 1. Analyze the biologic origin and chemical characteristics of carbon dioxide, explaining the key role of this molecule in acid-base equilibrium. 2. Briefly summarize the mechanisms regulating spontaneous breathing activity fundamental to understand the pathophysiology of respiratory acid-base disorders. 3. Summarize the physiologic compensatory mechanisms of respiratory acid-base derangements. 4. Analyze signs and symptoms of hypercapnia and hypocapnia. 5. Discuss causes of…

Metabolic Alkalosis

Objectives This chapter will: 1. Define alkalinity and alkalosis. 2. Discuss the pathophysiology of metabolic alkalosis. 3. Provide an algorithm for the differential diagnosis. 4. Address complications and options for medical management. Metabolic alkalosis, either as a primary disturbance or as renal “compensation” of hypercapnia, occurs in about 25% of critically ill patients and may contribute to overly prolonged mechanical ventilation and high patient mortality (reaching…

Renal Tubular Acidosis

Objectives This chapter will: 1. Define renal tubular acidosis. 2. Review the types of this disorder. 3. Describe the relevant renal acid-base physiology and pathophysiology. 4. Present clinical methods of diagnosis and differential diagnosis. 5. Discuss treatment. Definition Renal tubular acidosis (RTA) refers to metabolic acidosis, which is caused by the inability of the renal tubule to excrete an acid load because of either a genetic…

Hyperlactatemia and Lactic Acidosis

Objectives This chapter will: 1. Review the major factors that modulate physiologic lactate production and utilization. 2. Discuss the mechanisms that modulate lactate during critical illness. 3. Review acid-base aspects of lactic acidosis. 4. Review causes of lactic acidosis that have particular relevance to critical care practitioners. 5. Provide a framework for the approach to patients with lactic acidosis of unknown cause. Hyperlactatemia, clinically defined as…

Metabolic Acidosis

Objectives This chapter will: 1. Provide a brief review of the quantitative (physiochemical) approach. 2. Describe the effects of acidosis in human physiology. 3. Describe the source of body acids during health and major critical care syndromes through the lens of the physiochemical approach. 4. Discuss the association between metabolic acid type and outcome in critically ill patients. 5. Provide therapeutic considerations. Brief Review of the…

Acid-Base Physiology and Diagnosis of Disorders

Objectives This chapter will: 1. Review in depth and criticize some of the foundations for current acid-base discourse. 2. Describe a model based on the strong requirement for charge balance in any fluid. To facilitate this, the notion of strong ion difference, which is the difference in concentrations between totally dissociated bases minus totally dissociated acids, is employed. It will be demonstrated that the strong ion…

Laboratory Tests: Blood Gases, Anion Gap, and Strong Ion Gap

Objectives This chapter will: 1. Give a brief overview of blood gas measurement. 2. Define anion gap and strong ion gap and explain why these terms are used. 3. Explain the similarities and differences between anion gap and strong ion gap. 4. Illustrate how to use anion gap and strong ion gap and discuss their interpretation. Blood Gas Variables: Measured and Calculated Oxygen Tension and Hemoglobin…

Aldosterone Antagonists, Amiloride, and Triamterene

Objectives This chapter will: 1. Review the structure, mechanism of action, and biologic effects of aldosterone antagonists, amiloride, and triamterene (the potassium-sparing diuretics). 2. Contrast the properties of the potassium-sparing diuretics with other diuretic drugs. 3. Discuss the renal and extrarenal effects of aldosterone antagonism. 4. Review the use of aldosterone antagonists, amiloride, and triamterene in clinical practice. A class of diuretic drugs that act primarily…

Vaptans and the Treatment of Hyponatremia

Objectives This chapter will: 1. Explain vaptan characteristics. 2. Review the diagnosis and management of hyponatremia. 3. Review vaptans for use in treatment of hyponatremia, especially with heart failure, cirrhosis, and syndromes of inappropriate antidiuretic hormone secretion. Kidneys play an important role in maintaining homeostasis of electrolytes and water against large fluctuations of solute and water intake in normal conditions. However, maintenance of fluid homeostasis is…