The "Management Principles" chapter presents the usual approach to care for patients with a particular condition. In the "Evidence Outline" section, each author discusses the aspects of diagnosis and treatment that are subject to ongoing debate in the medical literature.
Endocrine Disease
Infectious Disease Robert C. Hyzy
Gastrointestinal Disease Robert C. Hyzy
Hematologic Disease Robert C. Hyzy
Surgical
Critical Care in Obstetrics Marie R. Baldisseri
Medical Ethics Robert C. Hyzy
Bauman, MD Pulmonary and Critical Care Medicine, University of Michigan Health System, Ann Arbor, MI, VS. Gay, MD-afdeling Pulmonary and Critical Care Medicine, University of Michigan Health System, Ann Arbor, MI, VS.
ER- ICU Shock and Resuscitation
Cardiac Arrest Management
Survival from out-of-hospital cardiac arrest improving over time: results from the Resuscitation Outcomes Consortium (ROC). Chest compression rates during cardiopulmonary resuscitation are suboptimal: a prospective study during in-hospital cardiac arrest.
Post-cardiac Arrest Management
The ventilation and oxygenation goals for post-cardiac arrest patients should be normoxia and normocarbia. Finally, tissue donation (cornea, skin and bone) is almost always possible if post-cardiac arrest patients die.
Undifferentiated Shock
Passive leg raise (PLR) may be the most accurate and applicable assessment of volume response (Fig. 3.6). Early pulmonary artery catheter use and outcomes in patients with shock and acute respiratory distress syndrome: a randomized controlled trial.
Hypovolemic Shock and Massive Transfusion
In addition, the implementation of chloride-restrictive resuscitation is associated with a significant decrease in the incidence of acute kidney injury and the use of renal replacement therapy [19]. Prevalence of low central venous oxygen saturation in the first hours of intensive care admission and associated mortality in patients with septic shock: a prospective multicenter study.
Acute Respiratory Failure: NIV Implementation and Intubation
Short-term non-invasive pressure support ventilation prevents ICU admission in patients with acute cardiogenic pulmonary edema. Non-invasive versus invasive ventilation for acute respiratory failure in patients with hematological malignancies: a 5-year multicenter observational study. Palliative use of non-invasive ventilation in end-of-life patients with solid tumours: a randomized feasibility study.
Effect of noninvasive ventilation vs oxygen therapy on mortality among immunocompromised patients with acute respiratory failure: a randomized clinical trial.
Diagnosis and Management of Tricyclic Antidepressant
Seizures are common with significant overdose of tricyclic antidepressants and are a predictor of poor outcomes. Dosing guidelines for the treatment of tricyclic antidepressant toxicity with intravenous lipid emulsion have not been established. One animal study showed that the use of hypertonic saline in the treatment of tricyclic antidepressant poisoning resulted in a statistically significant improvement in systolic blood pressure and narrowing of the QRS complex compared to sodium bicarbonate [26].
Intravenous lipid emulsion therapy does not improve hypotension compared with sodium bicarbonate for tricyclic antidepressant toxicity: a pilot randomized controlled study in a porcine model.
Management of Calcium Channel Blocker Poisoning
The use of calcium gluconate and calcium chloride in the treatment of calcium channel blocker toxicity seems intuitive. In recent years, high-dose insulin therapy for the treatment of calcium channel blocker poisonings has received increasing attention. Intravenous lipid emulsion therapy in the setting of calcium channel blocker toxicity may be beneficial for several reasons.
High-dose insulin therapy, an evidence-based approach to beta-blocker/calcium channel blocker toxicity.
Diagnosis and Management of Ethylene Glycol Ingestion
This can be understood when considering that an ethylene glycol level of 21 mg/dL (the threshold at which treatment is recommended) is expected to increase serum osmoles by only 4 mosm [2]. The elimination half-life of ethylene glycol varies from 14 to 20 hours in ADH inhibition [4, 6, 10]. The American Academy of Clinical Toxicology practice guidelines for the treatment of ethylene glycol poisoning.
Safety of ethanol infusions for the treatment of methanol or ethylene glycol poisoning: an observational study.
Accidental Hypothermia
High Should be checked routinely as time is often unknown PT/PTT High due to coagulation. Thoracic lavage and ECMO carry significant risk and should be reserved for those patients with cardiac instability [11]. Therefore, patients with instability or cardiac arrest should be sent to the nearest facility capable of these inter-.
It remains unclear whether aggressive extracorporeal rewarming with VA or VV ECMO should be initiated in patients without associated cardiac arrest.
Cardiac Disease
Management of Cardiogenic Shock
Cardiogenic shock (CS) occurs in approx. 8% of individuals who have STEMI, while 80% of CS cases are due to an acute MI [1, 2]. Currently available devices include the intra-aortic balloon pump (IABP), Impella® microaxial rotary pumps (2.5, CP and 5.0), TandemHeart®. There are several aspects in the management of patients with CS from an acute MI for which clinical equilibrium still exists.
Trends in the incidence, management, and outcomes of cardiogenic shock complicating ST-elevation myocardial infarction in the United States.
Management of Acute Heart Failure
A follow-up trial, Ultrafiltration Versus Intravenous Diuretics for Patients Hospitalized for Acute Decompensated Heart Failure (UNLOAD), found that UF achieved greater net weight loss and reduced readmission rates at 90 days [14]. The Nesiritide in Decompensated Heart Failure (ASCEND-HF) study showed that the use of this drug did not improve patient survival, reduce readmission rates, or increase end-organ function compared with placebo [16]. In 2010, the results of the Dopamine in Acute Decompensated Heart Failure (DAD-HF) trial showed that low-dose furosemide plus low-dose dopamine resulted in less hypokalemia and less renal insufficiency, but with similar 60-day mortality, readmission rates, and lengths of hospital stay [17].
Loop diuretic strategies in patients with acute decompensated heart failure: a meta-analysis of randomized controlled trials.
Management of Acute Coronary Syndrome
Early risk stratification in patients with ACS is essential to identify those at higher risk of adverse events. Statin therapy High-intensity statin (atorvastatin 80 mg or rosuvastatin 40 mg) should be initiated or continued in all patients with ACS. In addition to aspirin, a P2Y12 inhibitor should be administered for at least 12 months to all patients with ACS [16].
Effects of clopidogrel in addition to aspirin in patients with non-ST-segment elevation acute coronary syndromes.
Complications of Myocardial Infarction
The patient has demonstrated hemodynamic instability despite patency of the infarct-related artery in the setting of delayed presentation of acute myocardial infarction (AMI). An image of the transesophageal echocardiogram obtained in the standard 4-chamber view is given in Fig. The optimal timing for surgery in unstable patients with ventricular septal rupture is controversial given the extraordinarily high mortality of patients undergoing surgery. in the immediate period after the infarction [4].
Unfortunately, mortality remains high, comparable to surgical series [8].
Management of Cardiac Tamponade
Cardiac tamponade occurs when fluid accumulates in the intrapericardial space, increasing intrapericardial pressure and impairing cardiac filling [2]. In most cases, the treatment of cardiac tamponade should be oriented towards emergent drainage of pericardial effusion by percutaneous needle pericardiocentesis. Whenever possible, the procedure should be performed by an experienced provider in the cardiac catheterization laboratory.
Effusion-constrictive pericarditis (ECP) is a clinical syndrome in which narrowing of the visceral pericardium occurs in the presence of a tense pericardial effusion.
Hypertensive Crises
Optic disc diameter greater than 5 mm by ocular ultrasound (Fig. 15.2) has been shown to detect intracranial pressure greater than 20 with an AUC of 0.93 [3]. It is considered safe in patients with active coronary disease because the beta blockade does not cause reflex tachycardia. It is an arteriolar dilator, and it is administered in a lipid emulsion, and is contraindicated in patients with allergies to eggs or soy products [9].
It may increase intraocular pressure, so it should not be used in patients with glaucoma [10].
Atrial Fibrillation and Other Supraventricular Tachycardias
Amiodarone should be used with caution in patients with underlying lung, liver or thyroid disease. In patients with HFrEF and cardiac resynchronization therapy devices, rhythm control has a lower mortality rate [17]. A new user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey.
Cardiac Resynchronization Therapy in Patients with Atrial Fibrillation: The Cardiac Resynchronization Therapy in Atrial Fibrillation Patients Multinational Registry (CERTIFY) Study.
Ventricular Arrhythmias
Ventricular arrhythmias are divided into nonsustained (premature ventricular contractions and nonsustained VT) and sustained (defined as VT lasting more than 30 s or VF). Beta-blockers should be used in the initial phase of treatment for most patients with ventricular arrhythmias [2]. In the absence of acute ischemia, the use of lidocaine should be considered if sustained ventricular arrhythmias are refractory to beta-blockers and amiodarone.
Antiarrhythmic drugs are not effective in patients with persistent ventricular arrhythmias due to digoxin toxicity.
Management of Acute Aortic Syndromes
International Registry of Acute Aortic Dissection (IRAD) researchers found that beta-blockers were generally associated with mortality benefits in type A dissections and in patients treated surgically, while patients with medically managed type B dissections had improved survival if discharged home with calcium channel blockers [3]. A guideline-based approach to the management of patients with aortic dissection is provided in Fig. Type-selective benefits of medications for the treatment of acute aortic dissection (from the International Registry of Acute Aortic Dissection [IRAD]).
Diagnosis of acute aortic dissection by D-dimer: experience from the International Registry of Acute Aortic Dissection Substudy on Biomarkers (IRAD-Bio).
Management of Endocarditis
A pre-discharge echocardiogram showed a normally functioning aortic bioprosthesis with no evidence of infective endocarditis. Clinical presentation, etiology and outcome of infective endocarditis in the 21st century: the international collaboration on endocarditis - prospective cohort study. Effect of early cerebral magnetic resonance imaging on clinical decisions in infective endocarditis: a prospective study.
Influence of the timing of cardiac surgery on the outcome of patients with infective endocarditis and stroke.
Respiratory Disease
Community Acquired Pneumonia
Association between time of intensive care unit admission and outcomes for emergency department patients with community-acquired pneumonia. Minor IDSA/ATS criteria aid in pre-intensive care unit resuscitation in severe community-acquired pneumonia. SMART-COP: a tool for predicting the need for intensive respiratory or vasopressor support in community-acquired pneumonia.
Lower respiratory tract virus findings in mechanically ventilated patients with severe community-acquired pneumonia.
Management of Acute Respiratory Distress Syndrome
Risk Factors for ARDS and Diagnosis Several risk factors for the development of ARDS have been identified. In the case, the above presentation of the patient's history of chronic alcohol ingestion was a predisposing risk factor for the development of ARDS in what was likely to have been aspiration pneumonia, which itself is another risk factor. Although easily calculated, the P/F ratio does not take into account the effect of mean airway pressure on oxygenation.
Severity of ARDS is based on oxygenation criteria, which to some extent also account for the application of positive airway pressure.
