Anaesthesia, Pharmacology, Intensive Care and Emergency Medicine A.P.I.C.E.: Proceedings of the 23rd Postgraduate Course in Critical Care Medicine Catania, Italy — November 5 – 7, 2010

369 Pages·2011·2.52 MB·English

by  Antonino Gullo (eds.)

APICE 23
Antonino Gullo (Ed.)
A P
naesthesia, harmacology,
C
Intensive are
and Emergency Medicine
A.P.I.C.E.
Proceedings of the
23rd Postgraduate Course in Critical Care Medicine
Catania, Italy - November 5-7, 2010
Editor
Antonino Gullo
Department and School of Anaesthesia and
Intensive Care, Catania University-Hospital
Catania, Italy
ISBN 978-88-470-2013-9 e-ISBN 978-88-470-2014-6
DOI 10.1007/978-88-470-2014-6
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Contents
Part I Continuing Medical Education
1 Can I Think what I Read? ................................................................................ 1
Philip D. Lumb
Part II Clinical Pharmacology
2 Pharmacological Manipulation in ICU ........................................................... 9
Daniel De Backer, Katia Donadello and Sabino Scolletta
2.1 Effects of Fluids ..................................................................................... 10
2.2 Effects of Red Blood Cell Transfusions ................................................. 11
2.3 Effects of Inotropic Agents ..................................................................... 11
2.4 Effects of Vasopressor Agents ................................................................ 11
2.5 A Place for Vasodilatory Agents? ........................................................... 12
2.6 Effects of Agents with Anticoagulant Properties .................................... 13
2.7 Conclusions ............................................................................................ 13
References ........................................................................................................... 13
Part III Kidney
3 Renal Injury ...................................................................................................... 19
Vladimir Gašparovi(cid:254), Ivan Gornik
3.1 Introduction ............................................................................................ 19
3.2 De(cid:2) nition ................................................................................................ 19
3.3 Epidemiology ......................................................................................... 20
3.4 Aetiology ................................................................................................ 20
v
vi Contents
3.5 Differences Between Acute and Chronic Kidney Injury ........................ 20
3.6 Prerenal Acute Kidney Injury ................................................................. 21
3.6.1 Aetiology of Prerenal AKI...................................................................... 21
3.6.2 Pathophysiology of Prerenal AKI ........................................................... 21
3.7 Intrinsic Acute Kidney Injury ................................................................. 22
3.7.1 Aetiology ................................................................................................ 22
3.8 Pathogenesis of Acute Intrinsic Kidney Injury ....................................... 23
3.9 Postrenal Acute Kidney Injury ............................................................... 23
3.10 Clinical Presentation of Acute Kidney Injury ........................................ 23
3.11 Diagnostic Algorithm and Differential Diagnosis .................................. 25
3.11.1 Postrenal AKI ......................................................................................... 25
3.11.2 Prerenal or Intrinsic Renal AKI? ............................................................ 25
3.12 Treatment of Acute Kidney Injury .......................................................... 26
3.12.1 Fluid Balance .......................................................................................... 26
3.12.2 Hyperkalaemia ........................................................................................ 26
3.12.3 Metabolic Acidosis ................................................................................. 27
3.12.4 Diet ......................................................................................................... 27
3.12.5 Indications for Haemodialysis ................................................................ 27
3.13 Prognosis ................................................................................................ 28
3.14 Prevention ............................................................................................... 28
Further Reading .................................................................................................. 29
Part IV Ventilation: Adult and Paediatric
4 Respiratory Mechanics: Principles, Utility and Advances ............................ 33
Alysson R. Carvalho, Walter A. Zin
4.1 Introduction ............................................................................................ 33
4.2 Principles ................................................................................................ 34
4.2.1 Pleural Pressure ...................................................................................... 34
4.2.2 Elastic Recoil of the Lungs..................................................................... 35
4.2.3 Elastic Recoil of the Chest Wall ............................................................. 38
4.2.4 Elastic Recoil of the Respiratory System ............................................... 39
4.3 Resistive Properties ................................................................................ 40
4.3.1 Pulmonary Resistance ............................................................................ 40
4.3.2 Chest-wall Resistance ............................................................................. 42
4.3.3 Respiratory System Resistance............................................................... 42
4.4 Utility and Advances .............................................................................. 42
References ........................................................................................................... 44
5 Capnometry/capnography in Prehospital Cardiopulmonary Resuscitation 47
Štefek Grmec, Katia Lah and Štefan Mally
5.1 Introduction ............................................................................................ 47
5.2 Physiology and Clinical Applications of Capnography.......................... 47
Contents vii
5.3 Research of Capnometry/capnography in the Centre
for Emergency Medicine, Maribor ......................................................... 50
5.3.1 Capnography/capnometry and Veri(cid:2) cation of Endotracheal Tube
Placement ............................................................................................... 50
5.4 Capnography in Cardiac Arrest and Cardiopulmonary Resuscitation .... 52
5.5 Conclusions ............................................................................................ 54
References ........................................................................................................... 54
6 Weaning from Mechanical Ventilation ............................................................ 57
Irene Cortés Puch, Andrés Esteban
6.1 Introduction ............................................................................................ 57
6.2 Assessing Readiness for Weaning .......................................................... 58
6.2.1 Predictors of Adequate Spontaneous Breathing ..................................... 59
6.3 Spontaneous Breathing Trials ................................................................. 60
6.3.1 Duration of the Spontaneous Breathing Trial ......................................... 60
6.3.2 Criteria to De(cid:2) ne SBT Tolerance/Success ............................................. 61
6.4 Failure of the Spontaneous Breathing Trial ............................................ 61
6.4.1 Causes of Weaning Failure ..................................................................... 61
6.4.2 Management of Patients who Fail Spontaneous Breathing Tests ........... 62
6.4.3 Withdrawal of Ventilatory Support ......................................................... 63
6.5 Extubation............................................................................................... 65
6.5.1 Risks Related to Reintubation ................................................................ 66
6.6 The Role of Noninvasive Positive Pressure Ventilation ......................... 66
6.6.1 Noninvasive Positive Pressure Ventilation as a Weaning Method ......... 67
6.6.2 Noninvasive Ventilation for Respiratory Failure after Extubation ......... 68
6.6.3 Noninvasive Positive-Pressure Ventilation for Preventing Respiratory
Failure after Extubation .......................................................................... 69
6.7 Management of Sedation and Weaning .................................................. 70
6.8 Weaning in Special Populations ............................................................. 71
6.8.1 Critical-Illness Polyneuropathy (CIP) and Weaning .............................. 71
6.8.2 Neurological and Neurosurgical Patients ............................................... 72
6.8.3 Chronic Obstructive Pulmonary Disease................................................ 72
References ........................................................................................................... 73
7 Ventilatory Strategies in Acute Lung Injury .................................................. 77
Edoardo Calderini, Sara Sher and Eleonora Allegritti
7.1 Introduction ............................................................................................ 77
7.2 Ventilatory Support ................................................................................. 78
7.2.1 Ventilator-induced Lung Injury .............................................................. 78
7.2.2 Prone Positioning ................................................................................... 80
7.2.3 Noninvasive Respiratory Support........................................................... 80
7.3 Conclusions ............................................................................................ 84
References ........................................................................................................... 84
viii Contents
8 Mechanical Ventilation Beyond the PICU ...................................................... 89
Giancarlo Ottonello, Alessia Franceschi
8.1 Introduction ............................................................................................ 89
8.2 The Extent of the Problem ...................................................................... 89
8.3 Patient Care: A Multisystemic Approach ............................................... 90
8.3.1 Mechanical Ventilation ........................................................................... 90
8.4 Prescribing Home Ventilation: Certi(cid:2) cation and Documentation .......... 94
8.4.1 Attribution of Disability ......................................................................... 94
8.4.2 Handicapped Certi(cid:2) cation ...................................................................... 94
8.4.3 Rare Disease Certi(cid:2) cation ...................................................................... 94
8.4.4 School Attendance .................................................................................. 95
8.4.5 Worker Bene(cid:2) ts ...................................................................................... 95
8.5 Caregiver Training .................................................................................. 95
8.6 Follow-up and Emergency Admissions .................................................. 96
8.7 Ethics ...................................................................................................... 96
8.8 Conclusions ............................................................................................ 97
References ........................................................................................................... 97
Part V Cardiovascular Monitoring
9 The Nex(cid:2) n Monitor – A Totally Non-Invasive Cardiac Output Monitor .................. 103
Azriel Perel, Wilbert Wesselink and Jos Settels
9.1 Introduction ............................................................................................ 103
9.2 Principles of CCO Measurement by the Nex(cid:2) n HD .............................. 104
9.2.1 Continuous Measurement of Finger BP ................................................. 104
9.2.2 Transformation of the Finger BP Curve into a Brachial Artery Waveform 105
9.2.3 Calculating CCO from Brachial Arterial Pressure Waveform ................ 105
9.3 Validation of the Nex(cid:2) n HD ................................................................... 106
9.4 Clinical Applications .............................................................................. 106
References ........................................................................................................... 107
10 Doppler Echocardiography in ICU Patients: Does It Improve Outcome? .. 109
Jan Poelaert
10.1 Introduction ............................................................................................ 109
10.2 Doppler Echocardiography ..................................................................... 109
10.3 Echo-Doppler Diagnostic Tools ............................................................. 110
10.4 Immediate Bedside Haemodynamic Information ................................... 110
10.5 Right Ventricle ........................................................................................ 112
10.6 Preload and Fluid Responsiveness ......................................................... 113
10.7 Conclusions ............................................................................................ 113
References ........................................................................................................... 114
Contents ix
Part VI Management of Cardiac Arrest
11 Mild Therapeutic Hypothermia after Cardiac Arrest ................................... 119
Tommaso Pellis, Vincenzo Mione and Willy P. Mercante
11.1 Introduction ............................................................................................ 119
11.2 Mechanisms of Neuroprotection ............................................................ 119
11.3 Clinical Relevance .................................................................................. 120
11.3.1 Randomised Clinical Trials .................................................................... 120
11.3.2 Nonrandomised Clinical Trials ............................................................... 121
11.4 Complications of Mild Therapeutic Hypothermia ................................. 121
11.4.1 Changes in the Immune System ............................................................. 122
11.4.2 Effects on Coagulation ........................................................................... 122
11.4.3 Cardiovascular and Haemodynamic Effects .......................................... 122
11.4.4 Drug Metabolism .................................................................................... 123
11.5 Conclusions ............................................................................................ 123
References ........................................................................................................... 124
12 Nasopharyngeal Cooling During Cardiopulmonary Resuscitation ............. 129
Francesco Fumagalli, Giuseppe Ristagno
12.1 Introduction ............................................................................................ 129
12.2 Therapeutic Hypothermia Following Resuscitation from Cardiac Arrest .. 129
12.3 Nasopharyngeal Cooling During CPR ................................................... 131
12.4 Conclusions ............................................................................................ 135
References ........................................................................................................... 135
13 Amplitude Spectrum Area as a Predictor of Successful De(cid:2) brillation ........ 141
Giuseppe Ristagno, Yongqin Li, Antonino Gullo and Joe Bisera
13.1 Introduction ............................................................................................ 141
13.2 Monitoring Effectiveness of Chest Compression and Predicting
Return of Circulation .............................................................................. 142
13.3 Analyses of ECG Features During Ventricular Fibrillation and CPR .... 143
13.4 Amplitude Spectrum Area (AMSA) as Predictor of Successful
De(cid:2) brillation ........................................................................................... 145
13.5 Applicability of AMSA to the Clinical Scenario .................................... 150
13.6 Conclusions ............................................................................................ 153
References ........................................................................................................... 154
Part VII Advances in Experimental and Clinical Research
14 Physiopathology and Severity of Post-Resuscitation Myocardial Dysfunction:
Effects of Sodium-Hydrogen Exchanger Isoform-1 (NHE-1) Inhibitors and
Erythropoietin ................................................................................................... 163
Raúl J. Gazmuri, Iyad M. Ayoub and Jeejabai Radhakrishnan
x Contents
14.1 Introduction ............................................................................................ 163
14.2 Functional Manifestations ...................................................................... 164
14.2.1 Reductions in Left Ventricular Myocardial Distensibility ...................... 164
14.2.2 Resistance to De(cid:2) brillation .................................................................... 165
14.2.3 Reperfusion Arrhythmias........................................................................ 166
14.2.4 Postresuscitation Myocardial Dysfunction ............................................. 166
14.3 Novel Intervention Targeting the Pathophysiology of Myocardial Injury .. 166
14.3.1 NHE-1 Inhibitors .................................................................................... 167
14.3.2 Erythropoietin ......................................................................................... 170
14.4 Conclusions ............................................................................................ 172
References ........................................................................................................... 172
15 Experimental Treatment for Preservation of Mechanically Competent
Cardiac Activity Following Cardiac Arrest .................................................... 179
Iyad M. Ayoub, Jeejabai Radhakrishnan and Raúl J. Gazmuri
15.1 Introduction ............................................................................................ 179
15.1.1 Na+-induced Cytosolic Ca2+ Overload ................................................... 180
15.1.2 NHE-1 Inhibition during Ischaemia and Reperfusion ............................ 181
15.2 NHE-1 Inhibition Promotes Return of Electrically Stable
and Mechanically Competent Cardiac Activity ...................................... 183
15.2.1 Clinical Implications of NHE-1 Inhibition Treatment during Cardiac Arrest 189
References ........................................................................................................... 190
16 Erythropoietin Facilitates Return of Spontaneous Circulation and
Survival in Victims of Out-of-Hospital Cardiac Arrest ................................. 195
Štefek Grmec, Matej Strand and Raúl J. Gazmuri
16.1 Introduction ............................................................................................ 195
16.2 Effects on Resuscitation ......................................................................... 197
16.2.1 Studies in Rats ........................................................................................ 197
16.2.2 Clinical Study ......................................................................................... 198
16.2.3 Results .................................................................................................... 199
16.3 Erythropoietin in Cardiocerebral Resuscitation:
Potentially Neuroprotective Role of Erythropoietin? ............................. 201
References ........................................................................................................... 201
Part VIII Infections, Sepsis and Organ Dysfunctions
17 Pathophysiology of Resistance amongst Aerobic Gram-negative
Bacilli in Particular Acinetobacter Species ..................................................... 207
Nia Taylor, Luciano Silvestri and Hendrick K.F. Van Saene
17.1 Introduction ............................................................................................ 207
17.2 Philosophy: Carriage .............................................................................. 207
17.2.1 Low- and High-grade Carriage ............................................................... 207