Evidence-Based Practice of Critical Care

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Cover IFC Front matter Evidence-based practice of critical care Copyright Dedication Contributors Preface Is hypothermia useful to prevent brain injury after cardiac arrest? In other settings? Keywords: Mechanisms of action Randomized controlled trials of mild therapeutic hypothermia Timing and duration of cooling How to deliver therapeutic hypothermia Side effects of hypothermia Hypothermia for traumatic brain injury Hypothermia in stroke References 1 Has evidence-based medicine changed the practice of critical care? Keywords: Looking beyond single randomized controlled trials Small things make a big difference Accountability is important Do less, not more It is not just the intensivist Summary Key points References 2 Do protocols/guidelines actually improve outcomes? Keywords: What is a protocol? What is a guideline? How does a protocol differ from a guideline? Epidemiology of protocols in the intensive care unit Challenges for protocols in the intensive care unit Protocol-driven care versus individualized care Protocols and guidelines: Sepsis as a case study How to develop a protocol locally What outcomes should be used to validate a protocol or guideline? Summary References 3 What happens to critically ill patients after they leave the ICU? Keywords: Looking back to forward Within the intensive care unit On the medical wards Post-acute care Rehospitalization Long-term survival Long-term functional outcomes Resilience and posttraumatic growth Conclusion References 4 What can be done to enhance recognition of the post-ICU syndrome (PICS)? What can be done to prevent it? What can be done to treat it? Keywords: What problems are prevalent among survivors of critical illness? Which of the problems faced by survivors are consequences of critical illness? Why does it matter whether the problem precedes critical illness or is a consequence of critical illness? Given the absence of proven therapies, what can be done to enhance prevention, recognition, and treatment of PICS? Conclusion References 5 How have genomics informed our understanding of critical illness? Keywords: Introduction Genomics discovery methods—briefly Genomic diagnostic and prognostic biomarkers in sepsis Genomic diagnostic and prognostic biomarkers in sepsis Genomic predictive biomarkers in sepsis and septic shock Genomic diagnostic and prognostic biomarkers in acute respiratory distress syndrome Diagnostic and prognostic biomarkers in ARDS Genomic biomarkers in other critical illnesses Genomics for drug discovery References 6 Is oxygen toxic? Keywords: Introduction Mechanisms of toxicity—reactive oxygen species The evidence for toxicity—from bench to bedside Oxygen toxicity in practice—from the cradle to the grave Neonates Adults Hyperoxia and carbon dioxide Hyperoxia in cardiac arrest, traumatic brain injury, and stroke Therapeutic hyperoxia Surgical site infection Management and prevention of oxygen toxicity Hyperbaric oxygen therapy and oxygen toxicity References 7 What is the role of noninvasive respiratory support and high-flow nasal cannula in the intensive care client? Keywords: Introduction Delivery of mechanical noninvasive respiratory support Selecting patients for noninvasive respiratory support Contraindications to noninvasive respiratory support Applications of noninvasive respiratory support in the intensive care unit Best evidence/first-line therapy Chronic obstructive pulmonary disease Acute exacerbation Extubating COPD patients Acute cardiogenic pulmonary edema Moderate evidence for use Asthma Pneumonia Immunocompromised states Preoxygenation for intubation Postoperative respiratory failure Obesity hypoventilation syndrome Neuromuscular disease Palliative care Interstitial lung disease Conflicting evidence/deleterious effect Acute lung injury and acute respiratory distress syndrome Postextubation respiratory failure High-flow nasal cannula oxygen therapy High-flow nasal cannula in acute hypoxemic respiratory failure Prevention of postextubation respiratory failure Apneic oxygenation during intubation References 8 What is the role of PEEP and recruitment maneuvers in ARDS? Keywords: Introduction Ventilator-induced lung injury The open lung ventilation approach Clinical trials of PEEP strategies Clinical trials of recruitment maneuvers Individualized PEEP titration at the bedside Imaging Oxygenation response to PEEP Esophageal pressure Compliance curves Electrical impedance tomography Conclusion and future directions References 9 What is the best way to wean and liberate patients from mechanical ventilation? Keywords: Introduction Clinical suspicion that weaning may be possible Assessment of readiness to wean Predictors of successful weaning General limitations of the readiness-to-wean predictors Individual limitations of the readiness-to-wean predictors Spontaneous breathing trial Suitability for extubation Ventilator management of the difficult-to-wean patient Role of tracheostomy in weaning Consideration of weaning protocols References 10 How does mechanical ventilation damage lungs? What can be done to prevent it? Keywords: Introduction and definitions How do ventilators damage the lungs in patients? How to minimize lung damage Conclusions References 11 How should exacerbations of COPD be managed in the intensive care unit? Keywords: Prevalence of COPD Respiratory failure Clinical precipitants of respiratory failure Prognostic indicators in patients with acute exacerbations of COPD Management of COPD Corticosteroids Bronchodilators Antibiotics Oxygen therapy Assisted ventilation HFNC oxygen therapy Prognosis and outcomes End-of-life decisions in severe COPD References 12 Is diaphragmatic dysfunction a major problem following mechanical ventilation? Keywords: Introduction Definition and epidemiology Diagnostic criteria Epidemiology Pathogenesis Sepsis Metabolic factors Pharmacologic exposures Mechanical ventilation Clinical outcomes Potential therapies Prevention Treatment References 13 Ards: Are the current definitions useful? Keywords: Introduction Creating the berlin definition—an evidence-based consensus The berlin definition Comparing the berlin and AECC definitions Comparing the berlin definition to lung pathology Limitations of the berlin definition for recognition and management of ARDS Conclusion References 14 What are the pathologic and pathophysiologic changes that accompany ARDS? Keywords: Introduction Pathogenesis The exudative phase Activation of the innate immune system and platelets Alveolar-capillary barrier dysfunction and permeability pulmonary edema Activation of the coagulation cascade Proliferative phase Fibrotic phase Iatrogenic lung injury Physiologic consequences Impaired gas exchange Low compliance Increased dead space Pulmonary hypertension Pathologic findings References 15 What factors predispose patients to acute respiratory distress syndrome? Keywords: Predisposing conditions Risk modifiers Risk prediction models Hospital-acquired exposures References 16 What is the best mechanical ventilation strategy in ARDS? Keywords: Introduction Ventilator-induced lung injury Volutrauma Atelectrauma Patient self-inflicted lung injury Lung-protective ventilation PEEP optimization and recruitment maneuvers Driving pressure Modes of ventilation Volume-targeted vs. pressure-targeted ventilation Spontaneous breathing High-frequency oscillatory ventilation Neuromuscular blocking agents Prone positioning References 17 Is carbon dioxide harmful or helpful in ARDS? Keywords: Introduction Physiologic effects of hypercapnia The respiratory system Control of breathing Pulmonary vasculature Airways Lung tissue Respiratory muscles The cardiovascular system Tissue oxygenation supply vs. demand balance The central nervous system Intracellular mechanisms of action of CO2 Role in clinical ards Prevalence of hypercapnia Benefit vs. harm in ARDS Extracorporeal CO2 removal Controversies and areas of uncertainty Permissive hypercapnia and intracranial pressure regulation Permissive hypercapnia and pulmonary vascular tone Permissive hypercapnia—the role of buffering Permissive hypercapnia at the bedside—practical issues References 18 Does patient positioning make a difference in ARDS? Keywords: Introduction Prone positioning in ARDS Mechanisms of possible benefit Evidence/clinical trials Practical considerations Other positioning strategies Head of bed elevation Frequent turns Lateral position References 19 Do inhaled vasodilators in ARDS make a difference? Keywords: Introduction Physiologic rationale Nitric oxide Prostaglandins Comparisons of inhaled nitric oxide and prostaglandin Reconciling the rationale with clinical research findings Summary References 20 Does ECMO work? Keywords: Introduction Basics of ECMO History, evolution, and current status of ECMO ECMO physiology/gas exchange Contraindications VV ECMO cannulation strategies ECMO: The evidence for its use in ARDS Factors complicating the study of ECMO Timing of initiation ECMO centers References 21 What lessons have we learned from epidemiologic studies of ARDS? Keywords: Lesson 1: Critical care epidemiology is challenging Lesson 2: ARDS is rare in the population but common in the adult ICU Lesson 3: There are different ARDS phenotypes Lesson 4: ARDS is underrecognized and treatment strategies underutilized Lesson 5: ARDS may be preventable Lesson 6: The trends in ARDS incidence and mortality are unknown Conclusion References 22 What are the long-term outcomes after ARDS? Keywords: Introduction Survival after hospital discharge Respiratory outcomes after ARDS Symptoms Imaging Pulmonary function testing Health-related quality of life after ARDS Post intensive care syndrome after ARDS Physical impairments after ARDS Mental health and cognitive impairment after ARDS Conclusion References 23 How do I approach fever in the intensive care unit and should fever be treated? Keywords: Critically ill patients with neurological disease Critically ill patients with sepsis Critically ill patients without sepsis or neurological disease References 24 What fluids should be given to the critically ill patient? What fluids should be avoided? Keywords: Crystalloids Colloids In general ICU patients, what fluids should I give and what should I avoid? In patients with sepsis, what fluids should I give and what should I avoid? In trauma patients, what fluids should I give and what should I avoid? In patients with hemorrhagic shock, what fluids should I give and what should I avoid? In patients with burn injury, what fluids should I give and what should I avoid? Conclusions References 25 Should blood glucose be tightly controlled in the intensive care unit? Keywords: Pathophysiology and mechanism of action Presentation of available data based on systematic review Interpretation of data Conclusion References 26 Is there a role for therapeutic hypothermia in critical care? Keywords: Temperature monitoring Cooling methods Complications associated with therapeutic hypothermia Mechanism of action of hypothermia Hypothermia in cardiac arrest Therapeutic hypothermia in ischemic stroke Hypothermia for spinal cord injury Hypothermia for traumatic brain injury Hypothermia for acute myocardial infarction Hypothermia for hypoxic-ischemic encephalopathy Hypothermia in other clinical scenarios Conclusion References 27 How do I manage the morbidly obese critically ill patient? Keywords: Introduction Airway management Respiratory Deep venous thrombosis prophylaxis Pharmacotherapy Sedatives and analgesics Neuromuscular blockade Antimicrobial agents Anticoagulants Nutritional care Diagnostic imaging Intravenous access Outcomes of critically ill obese patients Conclusion References 28 How do I safely transport the critically ill patient? Keywords: Introduction Intrahospital transport of the critically ill Adverse effects Predicting adverse events during intrahospital transport Risk-to-benefit ratio of intrahospital transport Management of the transport Interhospital transfer Adverse effects Prediction of adverse events Planning of the transport Selection of personnel Mode of transport Equipment and monitoring Prehospital transport Retrieval systems Mode of transport Prehospital personnel Prehospital time Receiving care facility Specific interventions in the prehospital setting References 29 What are the causes of and how do I treat critical illness neuropathy/myopathy? Keywords: Neuromuscular weakness What are the causes of CIP and CIM? How CIP and CIM can be detected How to treat CIP and CIM Conclusions References 30 What is sepsis? What is septic shock? What are mods and persistent critical illness? Keywords: Introduction Historical perspective Sepsis-1 Sepsis-2 Sepsis-3 Definitions Pathobiology A response to infection The dysregulated host response Immune dysfunction Endocrinopathy Neural pathways Organ dysfunction Septic shock: Truly distinct from sepsis? A unifying hypothesis—mitochondrial dysfunction and bioenergetic reprioritization Sepsis-3 clinical criteria References 31 How do I identify the patient with sepsis? Keywords: Sepsis-1 and sepsis-2 Sepsis-3: An intellectual advance Sepsis-3 at the bedside qSOFA: A new screening tool for sepsis What has happened since sepsis-3? Conclusion References 32 Is there immune suppression in the critically ill patient - pro? Keywords: Sepsis induces clinical immunosuppression Mechanisms of immunosuppression in sepsis Diagnosing immunosuppression in the septic patient Potential therapies aimed at sepsis-induced immunosuppression Conclusion References 33 Is there immune suppression in the critically ill patientcon? Keywords: Introduction Reprogramming of circulating blood leukocytes Nature of the activating signal Unaltered functions of circulating leukocytes Tissue immune cells as the main source of inflammatory cytokines Enhanced activation within tissues References 34 Does the timing of antibiotic administration matter in sepsis? Keywords: Introduction How do we measure the timing of antibiotics in sepsis? What is the evidence that antibiotic timing matters in sepsis? Preclinical data Clinical data What are the limitations of existing evidence on early antibiotics’ benefits? What are the potential adverse effects of early antibiotics? Too early antibiotics Drivers of mistargeted treatment Consequences of mistargeted treatment Conclusions and future directions References 35 What is the role of vasopressors and inotropes in septic shock? Keywords: Hemodynamic derangement in sepsis Vasopressor therapy Norepinephrine Dopamine Dobutamine Epinephrine (adrenaline) Phenylephrine Vasopressin Catecholamine overload Uncommonly-used vasopressors/inotropes Levosimendan Phosphodiesterase inhibitors: Milrinone and enoximone References 36 Does monitoring the microcirculation make a difference in sepsis? Outcome? Keywords: Introduction Hemodynamic coherence Oxygen transport and the microcirculation Monitoring the microcirculation Nailfold capillaroscopy Hand-held video-microscopes Orthogonal polarization spectral technique Sidestream dark-field technique Incident dark field technique Clinical application of hand-held video-microscopes References 37 Are we getting any better at diagnosing sepsis? Keywords: Our evolving definition of sepsis New sepsis definitions and tools in clinical practice Identification of sepsis in clinical practice The role of diagnostic biomarkers Molecular diagnostics Biomarker panels Conclusion References 38 Do the surviving sepsis campaign guidelines work? Keywords: What are bundles? The need for bundles in severe sepsis and septic shock Is there evidence that application of the ssc bundles improves outcomes? Is there evidence that the ssc bundles are cost-effective? Conclusions References 39 Has outcome in sepsis improved? What works? What does not? Keywords: Have outcomes from sepsis improved? What has not worked? What has worked? Conclusion References 40 What happens to the autonomic nervous system in critical illness? Keywords: Introduction What is autonomic dysfunction? At what point does autonomic dysfunction influence the development of critical illness? Autonomic dysfunction at the very onset of critical illness Is autonomic dysfunction in critical illness induced by modern critical care strategies? Cardiovascular dysfunction in critical illness as a direct result of autonomic dysfunction Immune dysfunction in critical illness as a result of autonomic dysfunction Conclusions References 41 Is persistent critical illness a syndrome of ongoing inflammation/immunosuppression/catabolism? Keywords: Introduction Evidence that persistent critical illness is a syndrome of ongoing inflammation, immunosuppression, and catabolism The self-perpetuating cycle of PICS Inflammation/immunosuppression Emergency myelopoiesis Organ injury Catabolism in CCI Treatment and therapy References 42 How do I optimize antibiotic use in critical illness? Keywords: Antibiotic pharmacokinetic and pharmacodynamic considerations to minimize resistance and optimize effectiveness Antibiotic susceptibility testing and resistance Specific antibiotic classes β-lactams Carbapenems Quinolones Vancomycin Linezolid Daptomycin Tigecycline Aminoglycosides Colistin Conclusion References 43 How do I identify pathologic organisms in the 21st century? Keywords: Introduction Pathogen-targeted diagnostics Culture-dependent methods Culture-independent methods Host-targeted diagnostics Future perspectives References 44 How do I diagnose and manage catheter-related bloodstream infections? Keywords: Introduction Definitions Incidence and epidemiology Microbiology Diagnosis Treatment Prevention Arterial lines and peripherally inserted central catheter lines Conclusions References 45 How do I manage central nervous system infections (meningitis/encephalitis)? Keywords: Introduction Bacterial meningitis Epidemiology and microbiology Diagnosis Treatment Antimicrobial therapy Corticosteroids Temperature management Prophylaxis Complications Intracranial hypertension Stroke Seizures Outcomes Viral central nervous system infection Epidemiology and microbiology Diagnosis Treatment Outcomes and complications Central nervous system abscess Brain abscess Epidural abscess Cranial subdural empyema Central nervous system infections in the immunocompromised host and global traveler References 46 How can biomarkers be used to differentiate between infection and non-infectious causes of inflammation? Keywords: C-reactive protein Structure and function C-reactive protein dynamics C-reactive protein as a marker of infection C-reactive protein as a marker of postoperative infection C-reactive protein as a marker of nosocomial infections C-reactive protein as a marker of treatment success and failure Procalcitonin Structure and function Procalcitonin dynamics Procalcitonin as a biomarker of infection in the ICU Procalcitonin as a marker of postoperative infection Procalcitonin as a marker of nosocomial infection in the ICU Procalcitonin as a marker of treatment success or failure Conclusion References 47 What is ventilator-associated pneumonia? How do I diagnose it? How do I treat it? Keywords: Introduction Pathogenesis Host factors Hospital and unit factors Pathogen-related factors Diagnosis Screening tests (initial detection) Clinical evidence of VAP Laboratory evidence of VAP Imaging Microbiologic tests (confirmation) Respiratory tract sampling Processing of respiratory samples Microscopic analysis Cultures Respiratory viruses Differential diagnosis Treatment of VAP Empiric therapy Important antimicrobial considerations De-escalation of antimocrobial therapy Duration of therapy Prevention Ventilator-associated event definitions References 48 What is the role of invasive hemodynamic monitoring in critical care? Keywords: Introduction Invasive or noninvasive arterial pressure monitoring? Central venous pressure and central venous oxygen saturation The pulmonary artery catheter Transpulmonary thermodilution and pulse wave analysis Hemodynamic optimization with the pulmonary artery catheter or transpulmonary thermodilution References 49 Does the use of echocardiography aid in the management of the critically ill? Keywords: Introduction Focused echocardiography and advanced echocardiography are useful in the evaluation of undifferentiated shock Obstructive shock Cardiac tamponade Pulmonary embolism Left ventricular outflow tract obstruction Septic shock Cardiogenic shock Focused echocardiography and advanced echocardiography in the evaluation of ventricular function Evaluation of left ventricular function Evaluation of right ventricular function Advanced echocardiography in the assessment of hemodynamics Volume responsiveness: Predicting fluid responsiveness Right atrial pressure Left atrial pressure and diastolic function Systolic pulmonary artery pressure Cardiac output Focused echocardiography and advanced echocardiography in valvular disease Acute mitral regurgitation Acute aortic regurgitation Aortic stenosis Conclusion References 50 How do I manage hemodynamic decompensation in a critically ill patient? Keywords: Assessing volume responsiveness Use of systolic pressure variation and pulse pressure variation Inferior vena cava collapsibility on ultrasound Passive leg raise Mean systemic pressure Initial treatment—addressing hypovolemia/hypovolemic shock Identification and emergent management of vasodilatory shock Identification and emergent management of obstructive shock Abdominal compartment syndrome Auto-PEEP Tension pneumothorax Cardiac tamponade Identification and emergent management of cardiogenic shock Conclusion References 51 What are the best tools to optimize the circulation? Keywords: Introduction Background Static measures of volume responsiveness Dynamic measures of fluid responsiveness Compensated shock Pulse pressure variation and stroke volume variation Respiratory variation of vena caval diameter Passive leg raising End-expiratory occlusion test Jugular venous distension Echocardiographic measures of fluid responsiveness Assessment of vasomotor tone: Dynamic arterial elastance References 52 How should cardiogenic shock be managed (including assist devices)? Keywords: Epidemiology and etiology Diagnosis Management: An evidence-based approach Pharmacologic therapy Mechanical therapy Revascularization therapy References 53 How do I manage acute heart failure? Keywords: Vasodilators Diuretics Hemofiltration Inotropes Short-term mechanical cardiac support References 54 How do I diagnose and manage myocardial ischemia in the ICU? Keywords: Introduction Pathophysiology Definition Epidemiology Diagnosis Clinical presentation Electrocardiogram Biomarkers Cardiac troponin CK-MB High-sensitivity cardiac troponin Imaging Management Analgesics Oxygen Nitrates Beta blockers and calcium channel blockers Statins ACE inhibitors and ARBS Inotropes and vasopressors Coronary revascularization Antiplatelet therapy Anticoagulation Fibrinolytics References 55 How do I prevent or treat atrial fibrillation in postoperative critically ill patients? Keywords: What are the patient risk factors and perioperative conditions that increase the risk of POAF? What is the pathogenesis of POAF? What strategies are effective for the prevention of POAF? Antiarrhythmic agents Beta blockers Amiodarone Sotalol Calcium channel blockers and digoxin Electrolyte repletion and maintenance Magnesium Atrial pacing Reduction of perioperative stressors and modulation of the inflammatory response to surgery Corticosteroids Statins Perioperative anesthetic management Aggressive pain management Colchicine Evacuation of pericardial blood What is appropriate therapy for POAF in a hemodynamically stable patient: Rate control or rhythm control? Rate control Rhythm control Anticoagulation strategy before restoration of sinus rhythm: Atrial fibrillation for less than 48 hours Anticoagulation strategy before restoration of sinus rhythm: Atrial fibrillation for more than 48 hours What is appropriate management of POAF in a hemodynamically unstable patient? Should anticoagulation be instituted or continued after electrical cardioversion to sinus rhythm? References 56 How do I rapidly and correctly identify acute kidney injury? Keywords: Introduction The identification of highly susceptible patients Biochemical diagnosis Clinical diagnosis Conclusion References 57 What is the role of renal replacement therapy in the intensive care unit? Keywords: Introduction What are the conventional indications for initiating renal replacement in acute kidney injury? Intravascular volume overload and pulmonary edema refractory to diuretic therapy Metabolic acidosis refractory to medical management Hyperkalemia refractory to medical management Uremia Intoxication with a dialyzable drug or toxin Severe electrolyte derangement Should renal replacement therapy be initiated in acute kidney injury before complications have developed? Observational data Randomized controlled trials Does CRRT purify blood in sepsis? What is the role of high volume ultrafiltration in sepsis? Is continuous renal replacement therapy superior to intermittent hemodialysis for sepsis-associated acute kidney injury? Can ultrafiltration serve as a means of support for organs other than the kidney? Cardiac support Lung support References 58 What is the value of nondialytic therapy in acute kidney injury? Keywords: Introduction and epidemiology Intravenous fluid to prevent AKI Crystalloids versus colloids Choice of crystalloid Early goal-directed therapy Fluids and perioperative acute kidney injury Diuretics Loop diuretics Natriuretic peptides Dopamine Fenoldopam mesylate Novel biomarker-guided therapy Alkaline phosphatase Conclusion Acknowledgments References 59 How should acid-base disorders be diagnosed? Keywords: Introduction Scientific background What is an acid? What is a base? Acid-base balance Strong ions and weak acids Carbon dioxide Acid-base disorders Respiratory alkalosis Respiratory acidosis Metabolic acid-base abnormalities Acute metabolic acidosis Types of metabolic acidosis Lactic acidosis Ketoacidosis Acidosis in acute kidney injury (renal acidosis) Hyperchloremic acidosis Metabolic alkalosis Analytic tools used in acid-base chemistry The descriptive CO2-bicarbonate (boston) approach Anion gap approach The semi-quantitative (base deficit/excess (copenhagen)) approach Stewart (quantitative) approach Conclusions References 60 Is hyperchloremia harmful? Keywords: Introduction Brief chloride physiology Potential mechanisms of hyperchloremia’s adverse effects Retrospective observational studies of hyperchloremia Crystalloid clinical trials Crystalloid trials meta-analyses Conclusions from crystalloid clinical trials Covariation with non-anion gap metabolic acidosis Differences between available balanced crystalloid solutions Summary References 61 Dysnatremiaswhat causes them and how should they be treated? Keywords: Introduction Homeostatic mechanisms relating to sodium concentration Hyponatremia Pseudohyponatremia—when the [Na+] is not really low at all True hyponatremia Hypertonic hyponatremia Hypotonic hyponatremia Hypotonic hyponatremia with decreased ecf volume (hypovolemic) Hypotonic hyponatremia with normal ecf volume (isovolemic) Hypotonic hyponatremia associated with increased ecf volume (hypervolemic) Symptoms and complications of hyponatremia Clinical assessment of the patient with hyponatremia (fig. 61.4) Diagnostic workup for hypotonic hyponatremia (fig. 61.5) Symptom assessment and immediate treatment indications Predicting sodium rise Potential complications Osmotic demyelination syndrome Rapid overcorrection Severe hyponatremia management with continuous renal replacement therapies Hypernatremia Causes of hypernatremia Hypovolemic hypernatremia Isovolemic or hypervolemic hypernatremia Symptoms and signs of hypernatremia Assessment and treatment of hypernatremia Treatment of hypernatremia References 62 Why is lactate important in critical care? Keywords: Introduction Metabolism of lactate Lactate and acidosis Lactate and tissue hypoperfusion Other causes of increased lactate Clearance of lactate How and where to measure lactate levels Lactate measurements in emergency care Lactate measurement in the intensive care unit Goal-directed therapy using lactate levels How to use lactate in clinical practice References 63 How does critical illness alter metabolism? Keywords: Pathophysiology and mechanism of action Neurologic Cardiovascular Fluids, electrolytes, and nutrition Pulmonary Gastrointestinal Renal Immunologic Endocrine Available data Interpretation of data Summary References 64 How should traumatic brain injury be managed? Keywords: Introduction Systemic blood pressure and oxygenation Background Evidence Hypoxemia. Hypotension. Recommendations Cerebral perfusion thresholds Background Evidence Recommendations Intracranial pressure thresholds Background Evidence Recommendations Seizure prophylaxis Background Evidence Recommendations Management of elevated intracranial pressure: Hyperventilation Background Evidence Recommendations Hyperosmolar therapy Background Evidence Recommendations Surgical decompressive therapy Background Evidence Recommendations Anesthetics, analgesics, and sedatives Background Evidence Recommendations Prophylactic hypothermia and therapeutic normothermia Background Evidence Recommendations Brain oxygen monitoring Background Evidence Recommendations Steroids Background Evidence Recommendations Nutrition Background Evidence Recommendations References 65 How should aneurysmal subarachnoid hemorrhage be managed? Keywords: Introduction Emergency setting Subarachnoid hemorrhage-related complications Rebleeding Medical measures Antifibrinolytics Surgical and endovascular measures Timing Hydrocephalus Seizures Delayed cerebral ischemia Detection Prevention and treatment Hemodynamic augmentation strategies Endovascular treatments Magnesium Calcium channel blockers Statins Endothelin 1 receptor antagonists Hyponatremia Cardiac dysfunction Electrocardiographic abnormalities Cardiomyopathy Fever Anemia Conclusion References 66 How should acute ischemic stroke be managed in the intensive care unit? Keywords: Epidemiology and triage Classification Initial evaluation and treatment Admission to the intensive care unit Intracranial pressure monitoring of stroke patients Seizures Complications of mechanical thrombectomy Neurologic complications Malignant middle cerebral artery syndrome Hemorrhagic transformation Posterior fossa infarction Other complications in the stroke patient Infection Angiodema Acute respiratory distress syndrome Critical care of the stroke patient Airway management and mechanical ventilation Blood pressure management Fluid management Management of nutrition Glycemic management Temperature management References 67 How should status epilepticus be managed? Keywords: Epidemiology Classification Etiologies of status epilepticus Management of status epilepticus Initial treatment Established status epilepticus treatment Refractory and super-refractory status epilepticus treatment Pathophysiology Prognosis References 68 When and how should I feed the critically ill patient? Keywords: Introduction Metabolism: Critical illness versus starvation Assessment of nutritional status Enteral nutrition or parenteral nutrition Early or late parenteral nutrition (in patients unsuitable for /intolerant of enteral nutrition) Parenteral nutrition versus limited or no nutrition Enteral feeding—stomach or postpyloric Enteral feeding—gastric residual volume Enteral feeding—bolus or continuous Deliberate underfeeding (hypocaleric) and trophic feeding Nutrition in acute pancreatitis References 69 What does critical illness do to the liver? Keywords: Mechanisms and manifestation of liver dysfunction Impact of liver dysfunction on critical care pharmacology Hepatic adaptation to critical illness: The acute-phase response References 70 How do I manage a patient with acute liver failure? Keywords: Epidemiology Clinical presentation Initial assessment and management Prognosis Specific causes and related therapies Hepatic encephalopathy Treatment of hepatic encephalopathy and elevated intracranial pressure Grades I and II hepatic encephalopathy Grades III and IV hepatic encephalopathy Intracranial pressure monitoring Maintenance of cerebral perfusion pressure Control of elevations of intracranial pressure in patients with grade III or IV hepatic encephalopathy Coagulopathy Infection Acute kidney injury Hemodynamic support Mechanical ventilation Gastrointestinal bleeding Metabolic concerns Nutrition Transplantation Areas of controversy Therapeutic hypothermia N-acetylcysteine for nonacetaminophen-induced alf Hepatectomy and auxiliary transplantation Liver support systems Summary References 71 Is there a place for anabolic hormones in critical care? Keywords: Androgens Insulin Growth hormone Thyroid hormones References 72 How do I diagnose and manage acute endocrine emergencies in the ICU? Keywords: Diabetic ketoacidosis Pathophysiology Precipitating factors Clinical presentation Therapy Initial evaluation Fluid and electrolyte replacement Insulin therapy Complications Hyperosmolar hyperglycemic state Pathophysiology Precipitating factors Clinical presentation Therapy Insulin therapy Fluid and electrolyte replacement Complications Thyrotoxic crisis Pathophysiology Precipitating factors Clinical presentation Treatment Decreasing hormone production and secretion Decreasing peripheral conversion of T4 to T3 Antagonizing the adrenergic effects of thyroid hormone Supportive care Definitive treatment Myxedema coma Pathophysiology Precipitating factors Clinical presentation Therapy Hormonal replacement therapy Monitoring therapy Vasopressin deficiency in shock Pathophysiology Clinical presentation Therapy References 73 What is the current role for corticosteroids in critical care? Keywords: Introduction Septic shock Acute respiratory distress syndrome Prevention of ARDS Treatment of established ARDS Late treatment in persistent ARDS Community acquired pneumonia Acute exacerbation of chronic obstructive pulmonary disease Acute severe asthma Traumatic spinal cord injury Concerns regarding corticosteroid use References 74 How should trauma patients be managed in the intensive care unit? Keywords: Infrastructure Resuscitation Invasive hemodynamic monitoring Noninvasive hemodynamic monitoring Biomarkers Special considerations of shock Hypovolemic shock Septic shock Neurogenic shock Cardiogenic shock Special considerations of trauma patients The open cavity Traction/immobility Venous thromboembolism prophylaxis Intensive care unit protocols Tertiary examination The extended intensive care unit team Nursing Physical therapy Pharmacy Summary References 75 What is abdominal compartment syndrome and how should it be managed? Keywords: Pathophysiology and mechanism of action Diagnosis Pressure-volume metrics Adjunctive measurements Systemic impact of ACS Cardiovascular system Respiratory system Renal system Non-renal viscera Central nervous system Ocular system Management approaches References 76 How should patients with burns be managed in the intensive care unit? Keywords: Initial assessment and emergency treatment Fluid resuscitation Inhalation injury Infection/sepsis Burn wound excision Metabolic response and nutritional support Modulation of the hormonal and endocrine response Glucose control References 77 What is the best approach to resuscitation in trauma? Keywords: Introduction/background Pathophysiology of hemorrhagic shock Presentation of available data based on systematic review Choice of fluid Transfusion Uncontrolled hemorrhagic shock Endpoints of resuscitation Summary References 78 How do I diagnose and treat major gastrointestinal bleeding? Keywords: Introduction Etiologies Evidence Management of nonvariceal upper gastrointetsinal bleeding Management of acute variceal bleeding Small intestine bleeding Lower gastrointestinal bleeding Management of patients receiving anticoagulation Controversies References 79 How should the critically ill pregnant patient be managed? Keywords: Introduction Sepsis in pregnancy Identifying and diagnosing sepsis in pregnant or postpartum patient Management of sepsis Acute respiratory distress syndrome in pregnancy What is the optimum strategy for mechanical ventilation in a pregnant patient? What is the role of extracorporeal membrane oxygenation in refractory acute respiratory distress syndrome in obstetric pat ... Conclusion References 80 How do I diagnose and manage patients admitted to the intensive care unit after common poisonings? Keywords: Diagnosis Toxidromes Laboratory Dangerous poisonings: Two important agents Acetaminophen (paracetamol) Salicylates Management principles Decontamination and enhanced elimination References 81 When is transfusion therapy indicated in critical illness and when is it not? Keywords: Introduction Basis for transfusion of blood products—benefits and risks Packed red blood cell transfusion Plasma transfusion Cryoprecipitate transfusion Platelet transfusion Massive exsanguination and transfusion Recombinant factor VIIa Mechanism of action and clinical use Adverse events associated with recombinant factor VIIa Tranexamic acid Mechanism of action and clinical use Conclusion References 82 Is there a role for granulocyte-macrophage colony-stimulating factor and/or erythropoietin in critical illness? Keywords: Chronic critical illness Role of granulocyte-macrophage colony-stimulating factor Clinical studies Heterogeneity of trials Pathophysiology of anemia in intensive care unit patients Erythropoietin Erythropoiesis-stimulating agents Iron supplementation References 83 What anticoagulants should be used in the critically ill patient? How do I choose? Keywords: Warfarin Unfractionated heparin Low-molecular-weight heparin Intravenous direct thrombin inhibitors Parenteral indirect factor Xa inhibitors Direct oral anticoagulants Oral direct factor Xa inhibitors How do I choose in the ICU: Which anticoagulant for which patient? References 84 Is there a better way to deliver optimal critical care services? Keywords: Introduction The interprofessional team Intensivist staffing models Advanced practice providers Protocolization and decision support Quality measurement and improvement Regionalization ICU telemedicine Future directions References 85 How do critical care pharmacists contribute to team-based care? Keywords: Introduction Definition of clinical pharmacy Clinical teams defined Training and certification Practice framework Role of critical care pharmacists Impact of critical care pharmacists Research role References 86 What is the role of advanced practice nurses and physician assistants in the ICU? Keywords: Nurse practitioner and physician assistant roles Use of nurse practitioners and physician assistants in the ICU Conclusions References 87 Do the Guidelines for Brain Death Determination Need to Be Revised? INTRODUCTION HISTORY OF GUIDELINES FOR DETERMINATION OF BRAIN DEATH AND PROFESSIONAL SOCIETY ENDORSEMENT CONTENTS OF GUIDELINES FOR DETERMINATION OF BRAIN DEATH RATIONALE BEHIND GUIDELINES FOR DETERMINATION OF BRAIN DEATH PROBLEMS WITH GUIDELINES FOR DETERMINATION OF BRAIN DEATH Failure to Achieve Ubiquity Procedural Variability Conceptual Variability ATTACKS ON THE INTEGRITY OF GUIDELINES FOR DETERMINATION OF BRAIN DEATH REFERENCES 88 How do I diagnose, treat, and reduce delirium in the intensive care unit? Keywords: Definition Risk factors Pathogenesis Neuroinflammatory hypothesis Cholinergic deficiency hypothesis Monoamine axis hypothesis Serotonin Amino acid hypothesis Impaired oxidative metabolism Recognition of delirium Primary prevention Pharmacologic intervention References Ibc