Category Archives: Intensive care medicine

General aspects of intensive care

Overall patient management These critically ill patients require multidisciplinary care with: • Intensive skilled nursing care (patient/nurse ratio 1:1). • Regular physiotherapy. • Careful management of pain and distress with analgesics and sedation as necessary. • Constant reassurance and support. Critically ill patients easily become disorientated and psychologically disturbed. • Nutritional support

Brain death

Brain death means ‘the irreversible loss of the capacity for consciousness combined with the irreversible loss of the capacity to breathe’. Both these are essentially functions of the brain stem. Death, if thought of in this way, can arise either from causes outside the brain (i.e. respiratory and cardiac arrest) or from causes within the head. With the advent of artificial ventilation it became p

Adult respiratory distress syndrome

Definition and causes This syndrome was originally described in 1967 as acute respiratory distress in adults characterized by severe dyspnoea, tachypnoea, cyanosis refractory to oxygen therapy, a reduction in lung compliance and diffuse alveolar infiltrates seen on the chest X-ray. ARDS can therefore be defined as diffuse pulmonary infiltrates, refractory hypoxaernia, stiff lungs and respiratory distress. A P

WEANING

The respiratory muscles eventually become weak and uncoordinated as they perform no work during conventional mechanical ventilation. Moreover, there is usually some persisting abnormality of lung function. Thus, in patients who have been artificially ventilated for any length of time, spontaneous respiration usually has to be resumed gradually. Critical illness neuropathy This recently recognized acquired pol

Respiratory failure

Types and causes The respiratory system consists of a gas exchanging organ(the lungs) and a ventilatory pump (respiratory  muscleslthorax) either or both of which can fail and precipitate respiratory failure. Respiratory failure occurs when pulmonary gas exchange is sufficiently impaired to cause hypoxaemia with or without hypercarbia. In practical terms respiratory failure is present when the Pa02 is <8 kP

Renal failure

Acute renal failure is a common and serious complication of critical illness which adversely affects the prognosis. The importance of preventing renal failure by rapid and effective resuscitation, as well as the avoidance of nephrotoxic drugs (especially NSAIDs), cannot be overemphasized. Shock and sepsis are the commonest causes of acute renal failure in the critically ill but it remains important to diagnos

Diuretic therapy

Diuretics increase salt and water excretion by the kidneys, thereby decreasing ventricular filling pressure (pre-load). This is the major form of therapy in sodium retention with fluid overload. Vasodilator therapy In selected cases, after-load reduction may be used to increase stroke volume and decrease myocardial oxygen requirements by reducing the systolic ventricular wall tension. Vasodilatation also decr

Choice of fluid for volume replacement

BLOOD. This is conventionally given for haemorrhagic shock as soon as it is available. In extreme emergencies, uncross matched group 0 negative blood can be used, but an emergency crossmatch can be performed in about 30 min and is as safe as the standard procedure. Donor blood is often separated into its various components for storage, necessitating the transfusion of packed red cells to maintain haemoglobin

Left atrial pressure

In uncomplicated cases careful interpretation of the CVP is an adequate guide to the filling pressures of both sides of the heart. In many critically ill patients, however, this is not the case and there is a disparity in function between the two ventricles. Most commonly, left ventricular performance is worst, so that the left ventricular function curve is displaced downward and to the right. This situation

CLINICAL SIGNS

Although many clinical features are common to all types of shock there are certain important respects in which they differ: Haemodynamic changes in shock. Hypovolaemic shock 1 Inadequate tissue perfusion: (a) Skin-cold, pale, blue, slow capillary refill (b) Kidneys-oliguria, anuria (c) Brain-confusion and restlessness 2 Increased sympathetic tone: (a) Tachycardia, narrowed pulse pressure (b) Sweating (c) Blood pr