ABC of Intensive Care E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Serie: ABC Series
• Sprache: Englisch

Seitenzahl: 208

Veröffentlichungsjahr: 2011

Beschreibung

This new and updated edition is a practical guide to intensive care for the non-specialist, providing the core knowledge and principles of intensive care patient management.

From general principles through to critical care outreach and end of life care, it covers best practice management in the intensive care unit. It includes the key organ system support as well as monitoring, sepsis, brain-stem death, and nutrition in intensive care. There is also full coverage of organ donation.

This invaluable resource is highly illustrated in colour throughout with new images, references to key evidence, and further reading and resources in each chapter. It is ideal for junior doctors, medical students and specialist nurses working in an acute hospital setting and the ICU and neonatal ICU, and for anyone involved in the management and care of intensive care patients.

Endorsed by the Intensive Care Society (UK) and the Scottish Intensive Care Society.

This title is also available as a mobile App from MedHand Mobile Libraries. Buy it now from Google Play or the MedHand Store.

Leseprobe

Table of Contents

Series Page

Title Page

Copyright

Contributors

Preface

Foreword

Chapter 1: General Principles of Intensive Care Management

Places, People and Patients

Problems After Discharge

Further Reading

Chapter 2: Communication and Decision-Making in Intensive Care

Introduction

Handover

Team-working and Shared Responsibility

Interruptions

Decision-making and Diagnosis

How Do Clinicians Think?

Final Thought

Further Reading

Online Tutorial

Chapter 3: Monitoring

Introduction

Respiratory Monitoring

Cardiovascular Monitoring

Renal Monitoring

Gastrointestinal, Hepatic and Intra-abdominal Monitoring

Brain Monitoring

Further Reading

Online Tutorial

Chapter 4: Sedation

What is Sedation?

Why Do Patients in Intensive Care Require Sedation?

Drugs Used to Sedate Patients in Intensive Care

Optimum Sedation

Practical Aspects of Managing Sedation

Delirium

Sleep in Intensive Care

Summary

Further Reading

Online Tutorial

Chapter 5: Pathophysiology of Organ Failure

Introduction

Further Reading

Chapter 6: Severe Sepsis

Introduction

Definition

Clinical Presentation and Diagnosis

Patient Management

Ongoing Management

Further Reading

Online Tutorial

Chapter 7: Respiratory Support

Introduction

Oxygen Therapy

Airway Management

Mechanical Ventilatory Support

Weaning From Mechanical Ventilation

Further Reading

Online Tutorial

Chapter 8: Cardiovascular Support

Cardiovascular Physiology

Cardiovascular Malfunction

Target Areas for Diagnosis and Treatment

Further Reading

Chapter 9: Renal Failure

Definition and Staging Systems

Causes of Acute Kidney Injury

Epidemiology and Outcomes

Diagnosis and Evaluation

Generic Management

Specific Pharmacological Therapies

Renal Replacement Therapy

Renal Replacement Modality

Dose of Renal Replacement Therapy

Access and Anticoagulation

Nutrition

Further Reading

Online Tutorial

Chapter 10: Neurological Support

Introduction

History

General Principles

Glasgow Coma Scale (and Score)

Traumatic Brain Injury

Brain Trauma Foundation Guidelines: Summary

Subarachnoid Haemorrhage (Aneurysmal)

Acute Ischaemic Stroke

Intracerebral Haemorrhage

Non-traumatic Coma

Infection (Encephalitis, Meningitis, Abscess)

Seizure Control

Muscle Weakness

Imaging

Conclusion

Further Reading

Chapter 11: Liver Support

Introduction

Classification and Aetiology

Diagnosis

Coagulopathy

Hepatic Encephalopathy

Cardiovascular Management

Renal Dysfunction

Sepsis

Gastrointestinal and Metabolic Management

Liver Support Devices

Emergency Surgery

Conclusion

Further Reading

Online Tutorial

Chapter 12: Gastrointestinal Support

Introduction

Upper Gastrointestinal Bleeding

Normal Gastrointestinal Motility

Other Important Gastrointestinal Conditions

Further Reading

Chapter 13: Nutrition in the ICU

Nutritional Goals and Challenges in The Critically Ill

The Refeeding Syndrome

Nutritional Assessment

Calculating Nutritional Requirements in Critically Ill Patients

Routes of Feeding

Further Reading

Online Tutorial

Chapter 14: Critical Care Outreach

Track and Trigger Systems

Sepsis Recognition and Response

Critical Care Outreach Teams

Facilitating Discharge from Critical Care and Follow Up

The Importance of Ongoing Education and Support in the Recognition of, and Response to, Acute Deterioration

The Future

Further Reading

Chapter 15: End-of-Life Care

Introduction

Withdrawal and Withholding Treatment

Brain Death and Organ Donation

Further Reading

Index

This edition first published 2011, © 2011 by Blackwell Publishing Ltd

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Library of Congress Cataloging-in-Publication Data

ABC of intensive care / edited by Graham R. Nimmo, Mervyn Singer.—2nd ed.

p. ; cm.

Includes bibliographical references and index.

ISBN 978-1-4051-7803-7 (pbk. : alk. paper)

1. Critical care medicine. I. Nimmo, Graham R. II. Singer, Mervyn.

[DNLM: 1. Intensive Care—methods. 2. Critical Illness—therapy. WX 218]

RC86.A23 2011

616.02′8—dc22

2011008380

A catalogue record for this book is available from the British Library.

This book is published in the following electronic formats: ePDF 9781444345193; ePub 9781444345209; Mobi 9781444345216

Contributors

Sheila Adam

Head of Nursing, Surgery and Cancer Board, University College, London Hospitals, NHS Foundation Trust, London, UK

Peter J. D. Andrews

Consultant in Critical Care, Western General Hospital, Lothian University Hospitals Division; Professor, Centre for Clinical Brain Sciences, University of Edinburgh, UK

Anna Bachelor

Consultant in Anaesthesia and Intensive Care Medicine, Royal Victoria Infirmary, Newcastle-upon-Tyne, UK

Jonathan Ball

Consultant in Intensive Care, St. George's Hospital, London, UK

Simon Baudouin

Senior Lecturer in Intensive Care Medicine and Consultant in Intensive Care Medicine, Royal Victoria Infirmary, Newcastle, UK

Timothy W. Evans

Professor of Intensive Care Medicine and Consultant in Intensive Care Medicine, Royal Brompton Hospital, London, UK

Michael Gillies

Consultant Intensivist, Royal Infirmary of Edinburgh, Edinburgh, UK

James Haslam

Specialty Registrar in Intensive Care, St. George's Hospital, London, UK

Charles Hinds

Professor of Intensive Care Medicine, Barts and The London Queen Mary School of Medicine, London, UK

Chris Holland

Consultant in Adult Intensive Care; Lecturer, King's College Hospital, London, UK

Martin Hughes

Consultant in Anaesthesia and Intensive Care Medicine, Royal Infirmary, Glasgow, UK

Peter MacNaughton

Consultant in Intensive Care Medicine, Plymouth, UK

Marcia McDougall

Intensive Care Unit, Queen Margaret Hospital, Dunfermline, UK

Saif Al Musa

Clinical Research Fellow, St. George's Hospital, London, UK

Peter Nightingale

Consultant in Anaesthesia and Intensive Care, University Hospital of South Manchester, Manchester, UK

Graham R. Nimmo

Consultant Physician in Intensive Care Medicine and Clinical Education, Western General Hospital, Edinburgh, UK

Mandy Odell

Nurse Consultant, Critical Care, The Royal Berkshire NHS Foundation Trust, Reading, UK

Liam Plant

Consultant Renal Physician and Clinical Senior Lecturer in Nephrology, Department of Renal Medicine, Cork University Hospital, Cork, Ireland

Tony M. Rahman

Consultant Gastroenterologist and Intensive Care Physician, St. George's Hospital, London, UK

Andy Rhodes

Consultant in Intensive Care Medicine, St. George's Hospital, London, UK

Ben Shippey

Consultant in Anaesthesia and Critical Care Medicine, NHS Fife, Fife, Scotland

Alasdair Short

Consultant Intensive Care Physician, Broomfield Hospital, Chelmsford, UK

Mervyn Singer

Professor of Intensive Care Medicine, University College London, London, UK

Neil Soni

Consultant in Anaesthesia and Intensive Care Medicine, Chelsea and Westminster Hospital, London, UK

Tim Walsh

Consultant in Critical Care, Royal Infirmary of Edinburgh; Honorary Professor, University of Edinburgh, Edinburgh, UK

David Watson

Honorary Professor of Intensive Care Education, Barts and The London School of Medicine; Consultant in Intensive Care Medicine, Homerton University Hospital, London, UK

Julia Wendon

Preface

Patients who require intensive care are usually the sickest patients in hospital. This is evidenced by their high mortality, and survivors may have persisting morbidities that may continue well after hospital discharge. They suffer from myriad diseases and can be referred from a diverse range of clinical settings: the emergency department, operating theatres, wards and even outpatient clinics. They present to intensive care when their diseases impinge on and impair the body's normal physiological processes, resulting in organ failures that may involve one or a combination of respiratory, cardiovascular, renal, neurological, gastrointestinal, hepatic, metabolic or other systems. Multiple trauma and sepsis are two of the commonest conditions that lead to critical illness. In order for intensive care to be most effective the unwell patient must be recognized, treated and referred early. Their subsequent management in intensive care needs to be scrupulous.

We provide updates on important advances in the understanding of the pathophysiology of critical illness, improvements in organ support and an insight into the human aspects of intensive care which are so important, including decision-making, communication and end-of-life care. The fundamentals of intensive care are covered in succinct, easy-to-read chapters written by experts in each individual area. The sum is a cohesive and contemporary introduction to the realm and speciality of intensive care.

As you read this book much of the mystery and awe which often surrounds intensive care will be dissipated and a real understanding of what can be achieved for the critically ill patient will emerge. Reading this book will enhance your clinical experience if you are a medical or nursing student approaching your first exposure to intensive care, a postgraduate medic or nurse on your first attachment, or an advanced practitioner in training. It will provide the medical or surgical specialist or general practitioners with a real insight to what is happening to your (our) patient when they require intensive care.

Graham R. Nimmo

Mervyn Singer

Foreword

Twelve years have elapsed since the publication of the highly successful first edition of the ABC of Intensive Care. Its publication, promoted by the UK Intensive Care Society, marked a crucial phase in the development of the specialty of Intensive Care Medicine (ICM). In the preceding 47 years since intubation and ventilation was first used in the treatment of respiratory failure, intensive care units (ICUs) had developed rather haphazardly across the world, led generally by local enthusiasts. Thereafter, from the 1970s, Intensive Care/Critical Care Societies in many countries across the globe have driven forward the organisation and development of ICUs, and created the specialty of ICM.

In our introduction to the first edition, Mervyn Singer and I declared that the specialty of ICM was ‘coming of age’. Now, on reflection, this statement was perhaps a little optimistic at that time. Intensive Care Medicine in 1999 was largely practised within the walls of the ICU by a variety of clinicians from differing backgrounds with an interest in ICM; education and training programmes for future intensivists were still at a rudimentary level of development in many countries, and indeed the specialty was not even recognized as a distinct entity in most countries.

The intervening years have seen major advances notably in organisation and training, so that when this second edition appears on the bookshelves we shall truly be able to say that the specialty of ICM has come of age. Many doctors and nurses now choose ICM as their principal or sole specialty. Others in many specialties cannot function without regular interaction with and support from the critical care team. Increasingly, all doctors working in acute specialties receive basic training in ICM as part of their specialty training. Hospitals cannot function as emergency centres for medicine or surgery without the provision of an ICU and its attendant critical care team that provides care across the hospital.

Official recognition of our specialty was slow in coming, but in many countries across the globe this has now been achieved. The European Union has recognized ICM as a medical specialty, and in the United Kingdom an Intercollegiate Faculty of Intensive Care Medicine has been successfully established within the Royal College of Anaesthetists to supervise training, assessment and examination in the specialty, a development which 12 years ago was a distant dream.

Over these 12 years, there have been further developments in the understanding of the pathogenesis of sepsis and organ dysfunction, the technology of monitoring and organ function support, the importance of appropriate nutrition and, especially, in the area of early recognition and prompt treatment of the critically ill, ICU follow-up and post-ICU rehabilitation. The second edition will, hopefully, yield light on these and other important issues. While still dealing with individual organ system support as in the first edition, there are additional chapters on monitoring, sepsis, nutrition, sedation and outreach as well as broadening the chapter on “withdrawal of treatment” to include the whole subject of “end-of-life care”. Furthermore, important day-to-day issues of clinical decision-making and ‘handovers” to maintain continuity of care are addressed.

The second edition of the ABC, like the first, will aim to balance scientific aspects of knowledge with practical guidelines for the management of critically ill patients. It will provide a useful introduction to ICM for those pursuing a career in an acute specialty, who require to be familiar with the scope, philosophy and practicalities of ICU management, and in particular for those doctors and nurses who are entering into a period of training in the ICU.

Ian S. Grant

Retired Consultant Intensivist

Western General Hospital, Edinburgh

Chapter 1

General Principles of Intensive Care Management

Anna Batchelor1 and Peter Nightingale2

1Royal Victoria Infirmary, Newcastle-upon-Tyne, UK

2University Hospital of South Manchester, Manchester, UK

Overview

A Critical Care Unit:

is a specialized area concentrating care for the sickest patients in the hospital in one placeis staffed by a multidisciplinary team of doctors, nurses, physiotherapists and dieticians, among others, who combine treatment with constant patient observation, monitoring and supporthas the equipment and medication required to provide multi-organ supportneeds to be physically close to operating theatres, emergency departments and radiology servicesis only the starting point for the patient. Patients and their families have needs beyond organ support: rehabilitation, both physical and psychological, should start during the time in critical care

Places, People and Patients

The term ‘critical care’ is used to encompass both intensive and high-dependency patient care. This type of care is normally delivered in units separate from general wards where most patients are nursed. Some specialist wards may have ‘high-care’ areas, although these are seldom equipped or staffed to an equivalent degree. Patients who require intensive care are usually managed initially in wards, operating theatres, radiology or endoscopy suites, or the emergency department. The staff in these areas need to promptly assess the patient, recognize the severity of their underlying illness, and initiate immediate life-saving management, while, at the same time, contacting the intensive care unit (ICU). An online tutorial covering this aspect of pre-ICU care can be found at: http://www.scottishintensivecare.org.uk/education/index.htm

ICUs and high dependency units (HDUs) (Figure 1.1) are typically centrally located within a hospital near to the emergency department, operating theatres and radiology department, but may be located in other specialist areas such as burns centres. This central location is important to facilitate smooth patient transfer, e.g. to theatre for surgery or to the radiology department for imaging.

Figure 1.1 A critical care unit.

Nursing staff dedicated to the care of critically ill patients are trained specifically for this work; such patients are considered too ill to be cared for in a normal ward.

Intensive care is also called Level 3 (Figure 1.2) care, and is for patients requiring either invasive ventilation or the support of two or more failing organ systems.

Figure 1.2 A Level 3 patient.

High dependency care, also called Level 2 (Figure 1.3) care, is for patients needing non-invasive respiratory or other single organ failure support.

Figure 1.3 A Level 2 patient.

Treatment during a critical illness is not just about the patient. Caring for very sick patients is highly stressful to family, friends and carers, who all need support. Intensive care thus involves holistic support of the patient, family and friends, and also the referring staff.

The Unit

Critical care is a relatively new specialty with its beginnings rooted in the polio epidemics of the 1950s in Denmark, where mortality rates were drastically reduced by tracheal intubation, manual ventilation (by teams of medical students) and the gathering together of patients in a single site. Subsequent to this, Bjørn Ibsen established what is considered the first proper ICU in Copenhagen in 1953. Initially, only patients requiring artificial ventilation were admitted to ICUs but the recognition that there were other patients needing a higher level of monitoring, observation and care has led to the development of HDUs or units that cater for both Level 2 and Level 3 patients.

Units vary in size; in the UK most have between six and 20 beds. Some operate solely as ICUs admitting the most seriously ill patients, whereas some are a mixture of intensive and high dependency care. In smaller hospitals the coronary care unit may be utilized for high-dependency patients with non-cardiac problems. In critical care it is common to have many patients in a large open area with curtains or screens to ensure patient privacy, and to have a few separate cubicles in which patients who are infected or are at increased risk of infection (e.g. neutropenic patients) can be isolated. Nowadays units are being built with proportionately more cubicles. However, although single cubicles enhance privacy, maintain patient dignity, and possibly contribute to a reduction in cross-infection hazards, it can be more difficult and isolating for both the patient and the nurse caring for them. Studies have reported a higher incidence of preventable adverse events in patients isolated for infection control.

Only 2% of UK hospital beds are in critical care units compared with up to 25% in some US and German hospitals. It is not unusual for a critical care unit to be full. In this situation clinicians need to balance the needs of all the patients requiring higher level care. Difficult decisions may need to be taken. Patients are sometimes transferred between units because their care can be better delivered in a more specialist unit, for example after a head injury. Transfers not for the benefit of a patient sometimes have to occur because another patient is too ill to move and the unit is full. It is generally acknowledged that this is never an ideal situation. The transfer must be undertaken safely and with the consent of the patient, if possible, and of their family. The principles of medical ethics, beneficence, non-malificence, autonomy and justice can be used to guide practice.

There are many devices stationed by the bedside of a critically ill patient, including ventilators to support ventilatory function, machines to replace renal function (haemofiltration or haemodialysis), and a range of monitors, infusion and syringe pumps. Machines for blood gas analysis (including co-oximetry for carboxy- and met-haemoglobin) with the additional capability of measuring blood glucose, lactate, sodium, potassium, ionized calcium and total haemoglobin are usually sited within the ICU, thereby providing rapid access to these data.

A large amount of ancillary space is required for storage of equipment, including:

gas cylinders with legal standards for storagedisposable productsa wide range of drugslaundrychairs for patients and visitorsbeds (for when patients are in chairs).

Clean and dirty utility areas and facilities for disposal of rubbish are also mandatory. Visitors should have a dedicated waiting area, preferably with comfortable chairs and television, and possibly with refreshment facilities. Quiet interview rooms for discussions with family members are essential. With office space, this all necessitates at least as much space again as that occupied by patients.

People

Critical care is delivered by a multidisciplinary team led by consultant intensivists. Intensivists are expert in the management of the critically ill patient. They have undertaken training over a wide range of medical areas including anaesthesia, general medicine and intensive care. They have the necessary skills to deliver and supervise the care given to patients with a wide range of organ dysfunctions and disease processes. They see acutely ill patients wherever they are located within the hospital, and not just within the ICU. They have skills in unit management, including the areas of finance, personnel and administration. They are educators at the bedside and in the classroom, not only to fellow doctors but to all members of the team. They show leadership, both clinical and managerial. They are the patient's advocate.

The referring clinician should visit the unit regularly and consult on their patient's management. However, while in the unit, the patients are managed hour by hour by the intensivist. Trainee doctors will also be present in the unit 24 hours a day, usually at a ratio of one for every eight beds.

Training in intensive care in the UK has been overseen by the Intercollegiate Board for Training in Intensive Care Medicine; however, this function has now been assumed by the Education and Training Committee of the recently formed Faculty of Intensive Care Medicine. Training is in a base specialty plus periods of intensive care and complementary specialty training. A curriculum for a training programme leading to the award of either a single Certificate of Completion of Training (CCT) or dual CCTs in Intensive Care Medicine and another specialty has been approved by the General Medical Council and the first trainees will be admitted in 2012.

Nurses working in critical care require the skills necessary to care for severely ill patients, including the use of the multiplicity of equipment needed to keep these patients alive. In the UK the nurse–patient ratio is usually 1:1 for intensive care and 1:2 for high dependency care, compared to the ratio of between 1:6 and 1:10 on a general ward. They may be assisted by one or more support workers.

Other members of the multidisciplinary team include physiotherapists, pharmacists, dieticians, microbiologists, ward clerks and data clerks. Important input comes from other groups including the radiology and pathology departments.

Patients

The patients in the ICU are the sickest in the hospital. They will have at least one and often several organ systems that are failing and needing support. About 40% of admissions are due to a surgical cause; many of these patients will be admitted immediately after major elective surgery. The remainder will have a medical diagnosis and be referred from either the emergency department, general wards, other departments or transferred from other hospitals.

In assessing a patient for potential admission it is important to consider if their situation is reversible and if they have potential for recovery. An ICU admission is unpleasant and expensive and should generally be reserved for patients who can recover; an obvious exception is for patients who are potential organ donors. It is often difficult to be sure which patients will survive so, inevitably, many patients die in the ICU. Depending on the type of unit, about 20% of ICU patients will not survive. Of those who die most will do so because of failure to respond to treatment or because, in the long term, they are unable to overcome the stress of their illness, often because of severe underlying comorbidities. In these cases interventional treatment is withdrawn, after detailed discussion with colleagues and family members.

Care of the critically ill patient requires a systematic approach to assessment and management. When requesting an admission the referring consultant or delegated senior member of the team should provide a comprehensive history, results of investigations, the diagnosis and plan of action. Referrals should be seen as soon as possible and the treatment plan agreed. On admission the appropriate monitoring and treatment is undertaken and physiological goals are set. These are reviewed frequently and changed as necessary depending on the results of investigations or response to interventions.

In addition to support for their failing organs, ICU patients need fundamental care including adequate nutrition, pressure area care, thrombo-embolic and stress ulcer prophylaxis, oral hygiene and psychological support. Much of this is provided by the nurse caring for the patient.