Assessment of the risk:bene \201 t ratio for the move. Assessment of degree of stabilizati on required before movement. Assessment of security equipment and tubes. Safe storage and s towage of equipment on the transportation trolley. Transfer is associated with an increased likelihood of arrhythmias so PaO2 should ideally be normalized. Required competencies of accompanying staff Accompanying staff must be competent in the fol lowing: \200 \200 \200 \200 \200 \200 \200 \200 Airway device insertion and management. Chest drain insertion and management. Cardiovascula r monitoring. Sedation/paralysis. Mechanical ventilation with transportation ventilators. L ifting and handling. Managing access in con \201 ned spaces. Management during imaging, e. g. special issues relating to ventilation during MRI. INTRA-HOSPITAL transportation 645 See also: Endotracheal intubation, p42; Pulse oximetry, p144; CO2 monitoring, p146; ECG mon itoring, p162; Blood pressure monitoring, p164; Inter-hospital transportation \200\224road, p646; Inter-hospital transportation \200\224air, p648. 646 CHAPTER 37 Transportation of the critically ill Inter-hospital transportation \200\224road Many critically ill patients are transported bet ween hospitals on a daily basis, mainly by ambulance. Staff may be unfamiliar with the ambu lance environment and may suffer from motion sickness. There should be at least two attenda nts, one of whom should be a critical care medical prac- titioner, ideally with previous ex perience of transportation in a supernumerary capacity. They must be familiar with the tran sportation equipment and commu- nication systems. Transportation services should be organiz ed and co-ordinated to deliver safe, ef \201 cient, and timely inter-hospital transfer. Patient preparation The steps in preparation for transportation are Assessment, Control, Co mmunication, Evaluation, Preparation and Packaging, and Transportation (ACCEPT). The decision to move a patient between hospitals must be taken jointly by the most senior c linicians available at the referring and receiving hospitals. Evaluate the risk:bene \201 t ratio of transportation, staf \201 ng, and equip- ment needs based on the nature of the illness, urgency, vehicle availability, geographical factors, traf \201 c and weather cond itions. Patients should be properly resuscitated and stabilized prior to transportation. Hy povolaemia is poorly tolerated. Intubate if GCS \211 8. Intubated patients should normally be paralyzed and sedated. Chest drains can be placed on Heimlich-type valves. Patients sho uld be covered in an insulating blanket. Required staff competencies for road transportation In addition to the competencies require d for intra-hospital transportation: \200 \200 \200 \200 \200 \200 \200 \200 Ability to assess patients remotely. Understanding the limitations of resource and power in an ambulance. Understanding physiological effects of acceleration and deceleration. Famili arity with chains of communication and command. Use of diverse modes of communication and a ssociated protocols. Handling emergencies on the road; when to stop and when to divert. Und erstanding ambulance emergency drills. Understanding the law relating to blue light use etc . Vehicle design Guidance covering design, speci \201 cation, and equipment requirements for road ambulances are contained within European Committee for Standardization CEN 1789. A ty pe C ambulance is a mobile ICU designed and equipped for transportation, advanced treatment , and monitoring of patients. To ensure that critical care can be continued throughout the journey, these vehicles need to have a 240V AC generator capable of pro- viding 2.2kVA, wit h a back-up inverter \201 tted. There should be six 240V outlets, positioned to allow equ ipment in use to be safely connected without creating trip hazards. The vehicles should als o have three 12V jack sockets, a pair of 12V switched screw terminals, and one 12V cigar-li ghter size socket. The vehicle should provide secure, CEN-compliant anchorage \201 xings for essential equipment, e.g. a portable ventilator, up to 6 syringe drivers, volumetric pu mps, gas cylinders etc. There must be CEN com- pliant provision for the \201 xing of crit ical care trolleys of different design. The vehicles must carry a minimum of two HX oxygen cylinders and have storage for D size spares for the stretcher trolley. INTER-HOSPITAL transportation \200\224ROAD 647 Transportation preparation (ACCEPT) Assessment Be aware of the full patient history and current problems. Control Identify the leader and allocate tasks. Communication Make sure all communication is clear, source identi \201 ed, and involves all staff involv ed with patient dispatch and receipt. Evaluation Assess risks and bene \201 ts of transportation, equipment needed, and urgency. Preparation and packaging Prepare patient, equipment, and staff. Transportation Having identi \201 ed the mode of transportation and completed the preparation, transporta tion the patient. See also: Endotracheal intubation, p42; Pulse oximetry, p144; CO2 monitoring, p146; ECG mon itoring, p162; Blood pressure monitoring, p164; Sedatives and tranquilisers, p308; Muscle r elaxants, p310; Intra- hospital transportation, p644; Inter-hospital transportation \200 \224air, p648. 648 CHAPTER 37 Transportation of the critically ill Inter-hospital transportation \200\224air Aircraft are preferred for longer distance transf ers with \201 xed wing aircraft preferred for distances >150 miles. Time to organize air transportation should be taken into account when judging any advantage of speed over longer distances. Helicopters are generally less comfortable, and provide a more cramped environm ent than either ambulance or \201 xed wing aircraft. Particular problems of air transportation A lower barometric pressure reduces alveolar part ial pressure of oxygen (leading to hypoxaemia) and increases the volume of gas \201 lled cavities. Noise and vibration may increase pain and discomfort or contribute to nausea. Patient preparation Patient assessment to calculate risk:bene \201 t ratio of air transpor tation and staf \201 ng and equipment needs based on the nature of the illness, urgency of transfer, availability of transportation, mobilization times, geographical factors, traf \201 c and weather conditions. An increased FIO2 is mandatory for all aeromedical transfers where the cabin is not pressur ized to sea level barometric pressure. Pneumothoraces must be drained. Nasogastric tubes sh ould be inserted and placed on free drainage. Pneumoperitoneum and intracranial air are rel ative contraindi- cations to air transportation. Tissues may also swell and plaster casts s hould be split. Nausea and pain must be adequately controlled. Required staff competencies for air transportation In addition to the competencies required for road transportation the following are required: \200 \200 Understanding the limitations of resource and power in aircraft. Understanding the effects of altitude, vibration, and noise on physiology and monitoring. Understanding emergency dri lls for helicopters and \201 xed wing aircraft. INTER-HOSPITAL transportation \200\224AIR 649 See also: Endotracheal intubation, p42; Chest drain insertion, p84; Enteral feeding and dra inage tubes, p122; Pulse oximetry, p144; CO2 monitoring, p146; ECG monitoring, p162; Blood pressure monitoring, p308; Sedatives and tranquilisers, p310; Muscle relaxants, p312; Intra hospital transportation, p644; Interhospital transportation \200\224road, p646. This page intentionally left blank 651 Chapter 38 Death and the dying patient Brain stem death 652 Withdrawal and withholding treatment 654 Care of the potential organ/t issue donor 656 652 CHAPTER 38 Death and the dying patient Brain stem death \200 Correct diagnosis allows discontinuation of futile ventilation and enables potential retrie val of organs for donation. Diagnosis is usually followed by asystole within a few days. Be fore brain stem function testing can be performed to con \201 rm the diagnosis, the patien t must have an underlying irreversible condition compatible with brain stem death. There mu st be no evidence that coma is due to hypothermia, depressant drugs, signi \201 cant metab olic abnormality, or muscle relaxant effect. Performance of brain stem death tests should n ot proceed until relatives, and medical and nursing staff have had a chance to take part in discussions. The test itself does not require consent. Cessation of mechanical ventilation is seen, incorrectly, by many lay people as the \201 nal point of death. If considering organ donation, involve the transplant coordinator early. \200 Brain stem death testing Procedures vary internationally. In the UK, assessment of brain st em re \202 exes must be performed by two doctors registered for >5 years, com- petent in t he \201 eld of brain stem death testing, and not members of the transplant team. At least one should be a consultant. An EEG is required in other countries. Pupillary light re \202 ex Pupils should appear \201 xed in size and fail to respond to a light stimulus. Co rneal re \202 exes These should be absent bilaterally. Pain response There should be no cranial or limb response to supraorbital pain. Vestibulo-o cular re \202 exes After con \201 rming that the tympanic membranes are clear, unobstruct ed, and non-perforated, 20mL iced water is syringed into the ear. The eyes would normally d eviate toward the opposite direction. Absence of move- ment to bilateral cold stimulation c on \201 rms an absent re \202 ex. Gag or cough re \202 ex The gag re \202 ex is absent in brain stem death. However, the gag re \202 ex is often lost in patients who are intubat ed. In these patients, cough re \202 ex in response to bronchial stimulation must be absen t. Apnoea test While the re \202 ex assessments are being performed, the patient should be pre-oxygenated with 100% oxygen. Disconnect the ventilator and pass 6L/min oxygen into the trachea via a catheter. Apnoeic oxygenation can sustain SaO2 for prolonged periods, but th ere is an inevitable rise in PaCO2 which should stimulate respiratory effort. After 3 \200 \22315min of dis- connection, blood gas analyzes are performed until PaCO2 >6.65kPa. Any re spiratory effort negates the diagnosis of brain stem death. Time of death Death is not pronounced until the second test has been completed, but the leg al time of death is when the \201 rst test indicates brain stem death. BRAIN STEM DEATH 653 See also: Blood gas analysis, p154; EEG/CFM monitoring, p204; Electrolytes (Na+, K+, Cl \200\223, HCO3 \200\223), p212; Toxicology, p224; Hypoglycaemia, p600; Hypothermia, p606; Care of the potential organ/tissue donor, p656. 654 CHAPTER 38 Death and the dying patient Withdrawal and withholding treatment This is arguably the most dif \201 cult and stressful decision that has to be made for the critically ill patient. \200 Withdrawal involves reduction or cessation of vasoactive drugs and/or respiratory support. In some Critical Care Units, the patient is heavily sedated and disconnected from the venti lator. Withholding involves non-commencement or non-escalation of treatment, e.g. applying an upper threshold dose for an inotrope, not starting renal replacement therapy. Discussion with patient and/or family Before approaching the patient/family, there should b e a consensus among medical and nursing staff that quantity and/or quality of life are sign i \201 cantly compromised and unlikely to recover. Often, the patient \200\231s viewpoint is very well-de \201 ned and carers may rue the fact that the discussion was not initiated earlier. Ethnic, cultural, and religious factors will in \202 uence both doctor and patient/family in the timing and frequency of such decisions. In some soci- eties, doctors have a more pat ernalistic approach with little involvement of patient and/or family in the decision-making process. Others are overly inclusive, sometimes to the point of excessively acquiescing to the fami- ly \200\231s demands despite obvious futility in continuing care. Clearly, a bal ance needs to be struck that serves the best interests of the patient. Although potentially awkward, the mentally competent patient should be involved as this is the most important decision affecting their life. This should be done as considerately as p ossible, avoiding unnecessary distress. A series of discussions may be needed over several days, allowing time to contemplate. Consensus is reached with >95% of patients/families by the third discussion. It should be stressed that care is not being withdrawn/withheld; pain relief, comfort, hydr ation, and general nursing care will be continued. Likewise, decisions are not \201 nal, but can be amended depending on the patient \200\231s progress, e.g. moving from withholdin g to withdrawal or re-institution of full treatment. A \200\230negotiated settlement \200 \231 is often a useful interim compromise for families unable to accept a withdrawal decisi on, whereby limitation of treatment is instituted and subsequently reviewed. Relatives can sometimes be very distraught and, occasionally, irrational on discussing with drawal/withholding. For many, this will be their \201 rst experience of the dying process in a loved family member. A number of other factors, including guilt, anger, and within-fa mily disagreements may also surface. It should be stressed that the withdraw/withhold decis ion is a medical recommendation and their passive agreement is being sought. The emphasis o f the discussion is to inform them of the likely outcome and to seek their view of what the patient would want. They need to be dealed with both sensitively and honestly, and they sh ould not feel pressured to give instant decisions. Discussions should involve the patient \200\231s nurse and other involved carers as appropr iate. It should be accurately documented in the case notes to ensure good communication bet ween caregivers and act as source data should subsequent complaints surface. WITHDRAWAL AND WITHHOLDING TREATMENT 655 Key paper Sprung CL, Cohen SL, Sjokvist P et al for the Ethicus Study Group. (2003) End-of- life practices in European intensive care units: the Ethicus Study. JAMA 290:790 \200\2237. See also: Communication, p18. 656 CHAPTER 38 Death and the dying patient Care of the potential organ/tissue donor Patients with suspected brain stem death should be considered candidates for organ or tissue donation. Tissue donation is excluded if there i s: \200 \200 \200 \200 \200 \200 There are few absolute contraindications to so lid organ donation: \200 \200 Systemic malignancy (other than for eye donation). HIV, HTLV, or hepatitis B or C positive or behavioral risk. Syphilis. Creutzfeldt \200\223Jacob disease (CJD) or family history of CJD. Progressive neurological disease of uncertain pathophysiology. Previous transplantatio n. HIV positive. CJD or suspected CJD. The transplant coordinator should be contacted early (before the family is approached) to c on \201 rm likely suitability. If the family is amenable, the transplant coordinator will then initiate organ donation procedures. Do not reject brain dead potential donors who, for example, have fully treated infections or acute renal failure without consultation with th e transplant coordinator. Management 1. Con \201 rm brain stem death with appropriate testing. 2. Laboratory tests f or blood group, HIV and hepatitis status, and electrolytes. 3. Con \201 rm organ donation is permissible by the coroner (or equivalent). 4. Maintain o ptimal cardiorespiratory status with \202 uid 9 inotropes and vasopressin, optimal ventilation, low PEEP, and physiotherapy. 5. Diabetes insipidus should be treated with DDAVP. 6. Maintain hemoglobin >9g/dL and corre ct coagulation disturbance. 7. Maintain body temperature with warmed \202 uids and heated blankets. 8. Contact surgical and anesthetic teams. Organ suitability \200 \200 \200 \200 Kidneys. Heart. Lungs. Liver. The transplant coordinator will advise on other organ and tissue suitability, e.g. pancreas , trachea, bowel, skin. Non-heart beating donation Solid organs suitable for transplantation from non-heart beating donors include kidneys, livers, and lungs. Tissue donation (e.g. corneas, etc.) should als o be considered in asystolic cadaveric donors. Contraindications are similar to those for b rain stem dead heart-beating donors. Consideration of non-heart beating donation should be made in all patients in whom treatment is to be withdrawn. CARE OF THE POTENTIAL ORGAN/TISSUE DONOR 657 See also: IPPV \200\224adjusting the ventilator, p50; Positive end expiratory pressure (1), p66; Positive end expiratory pressure (2), p68; Chest physiotherapy, p90; Blood gas analys is, p154; Full blood count, p220; Coagulation monitoring, p222; Virology, serology and assa ys, p226; Blood transfusion, p248; Vasopressors, p268; Hypothermia, p600; Brain stem death, p652. This page intentionally left blank 659 Index Please note the use of bold type indicates major coverage of a subject. A A2 antagonists 308 abdominal sepsis 422 ACCEPT acronym for transportation preparation 647 amiodarone 272 \200\2233, 340, dioxide (PaCO2) 50, 63 arterial partial pressure of oxygen (PaO2) 50, 63 385, 391 amniotic \202 uid embolus 640 amphetamine arterial puncture 172 aspiration 356, 374 aspirin 276 \200\2237, 303, 391, 452 asthma 364, 366 atelectasis 352 atenolol 391 atracurium 310 \200\22311, 366 atrial \201 brillation 38 4 atrial \202 utter 384 atropine 340, 391, 459, 540 audit 24 azathioprine 459 poisoning 530 amphotericin 327, 359, aciclovir 327, 359 acid-base disturbance 56, 401, 447 ampicillin 327, 359, 447 anemia 472 analgesia 584, 588, 624 epidural 306, 619 and Guillain- Barr syndrome 456 non-opioid 302 opioid 304 regional 618 systemic 618 154, 155 acid-base principles 500 acidosis 500, 502 activated clotting time 222 activated partial thromboplastin time 222 activated protein C 332, 560 actual base excess 152 acute physiolog y score 29 acute respiratory B B2 agonists 254 bacteraemia 553 bacteriology 224 barbiturate poisoning 526 B-blockers 272 \200\2233, 276 benzodiazepines 308, anaphylactoid reactions distress syndrome 360, 362 acute ventilatory 248, 578 anginal pain 388 angiodysplasia 420 angiotensin converting enzyme (ACE) inhibitors 267, 271 insuf \201 ciency (type II respiratory failure) 38, 44 444, 526 adenosine 272 \200\2233, 385 adrenaline 578 adverse drug reaction and anion gap 212 antacids 290 anti-arrhythmics 272 antibiotic assays 226 \200\2237 antibiotic regimens 555, benzylpenicillin 327, 359 beriplex 323 bicarbonate 152, 212, 340 biochemical/metabolic urin alysis tests 233 bioenergetic pathway from oxidation of glucose 237 bio-occlusive dressings 138 BiPAP (bilevel positive airways pressure) 76 Bird ventilator (inspiratory pressure sup port) 90 bispectral index monitor 204 blast injury 596 bleeding disorders 468 bleeding vari ces 414 blood: pyrexia 602 agitation, severe, drug dosages for 443 564, 610 air embolism 172 air \202 ow limitation, chronic 354 air \202 uidised bed 140 air mattre ss 140 air trapping assessment anticoagulants 102, 110, 318 anti-constipation agents 298 anticonvulsants 312, 444 anti-diarrhoeals 296 antidiuretic hormone (ADH) secretion, inappro priate 487 (PEEP) 366 airway maintenance 40 airway obstruction 348 airway pressure 46 airway protection 338 AIS90 (Abbreviated Injury anti-emetics 292 anti \201 brinolytics 322 antigen detection blood clot embolus 376 cultures 224 gas analysis 154 gas machine 152 gas values 362 lactate, meas urement Score 1990) 34 samples 224 albumin 246 \200\2237 alfentanil 304 \200\2235 alkalosis 500, 504 allopurinol 401 alprostad il 267, 318, 330 alteplase 320 \200\2231, 391 alveolar-arterial oxygen antimicrobials 326, 359, 554 APACHE scoring 28, 30, 32 aplastic crisis 474 apnoea test 652 apnoeic patient 48 arrhythmia s 172, 610 artemether 569 arterial cannulation 166 arterial monitoring, invasive of 236 pressure monitoring 164 difference 148 products 250 samples for antigen/ molecular detection 224 alveolar gas equation 149 ambient heating 602 amikacin 327 amiloride 281 aminophylline 254 \200\2235, 578 (direct) 164 arterial partial pressure of tests 392 transfusion 248, 602 carbon 660 INDEX central venous pressure cardiomyopathy 626 cardiovascular care bone: marrow (CVP)/pulmonary artery wedge pressure (PAWP) response 342, 343 cerebral blood \202 ow suppression 626 and Guillain-Barr syndrome 456 botulism 438 antitoxin and botulism 464 bowel failure cardiovascular disorders 379 (CBF) 206 cerebral function monitor 204 bradyarrhythmias 386 coronary syndrome, acute to open 410 ischaemic/infarcted 420 obstruction, upper 406 brachial artery 388, 390 cerebral heart failure 392, 394 hypertension 382 hypotension 380 tachyarrhythmias 384 cardiovascular drugs 263 anti-anginal agents 276 anti-arrhythmics 272 chronotropes 274 hypotensive agents 270 inotropes 264 vasodilators 266 vasopressors 268 microdialysis 206 cerebral protection 610 cerebrospinal \202 uid (CSF) values in meningit is 447 cannulation 166 bradyarrhythmias 386 bradycardia 386 brain natriuretic peptide cerebrovascular accident (CVA), new onset 440 chemotherapy, effects (BNP) 216 brain stem death 652 breathing, reducing work of 626 of 44 chest drain insertion 84 chest infection, acute bretylium 272 \200\2233 bronchial samples 224 bronchodilators 254 bronchopleural \201 stu la 368 bronchospasm 579, 610 bumetanide 281 bupivacaine 303, 306 \200\2237 burns see trauma and burns 356, 358 chest physiotherapy 90 chest X-ray 356, 356, 357 bronchopleural \201 stula 369 heart fail ure 392 respiratory imaging 158 chloramphenicol 327 chloride 212 chlorphenamine 578 \200 \2239 chlorpromazine 308 \200\2239, 443 cholestasis markers 218 cholinergic cardiovascular monitoring 161 arterial cannulation 166 blood pressure monitoring 164 echocardiography 192 electrocardiogram monitoring 162 gut tonometry 196 pres sure and stroke C calcitonin 495 calcium: 214 alginate 138 channel blockers 276 chloride 340 calorie requir ements 126 calorimetry, indirect 234 capnogram 146 \200\2237 capnography 146 captopril 395 carbamazepine 312 carbon: dioxide monitoring 146 monoxide 534 see also arterial partial volume variation 190 pulmonary artery catheter (anticholinesterase) syndrome 540 cholinergic crisis 458 chronic health points 29 chronotro pes 274 chylothorax 172 cimetidine 286 \200\2237 cipro \202 oxacin 327 circulation 338 cir culatory management: and head injury 588 post-operative 620 and pre-eclampsia and eclampsia 634 174, 176 tissue perfusion monitoring 194 see also cardiac output; central venous catheter cardiovascular support and amniotic \202 uid embolus 640 cardiovascular therapy techniques 93 coronary revascularisation pressure; techniques 104 electrical cardioversion partial pressure and spinal cord injury 590 and trauma 582 cisatracurium 310 \200\22311 citrate toxicity 248 clarithromycin 359 clindamycin 327, 359 clinical effectiveness 22 clinical experience 4 cl inical governance 22 clonazepam 313, 445 clonidine 302 \200\2233, 306, cardiac arrest 340, 488 cardiac enzymes 216 \200\22317 cardiac function tests 216 cardiac i ndex 177 cardiac massage 340 cardiac output: 94, 95 intra-aortic balloon counterpulsation 102 temporary pacing 96, 98 therapeutic hypothermia 100 cardioversion 340 caspofungin 327 ceftazidime 327, 359 ceftriaxone 327, 447 cefuroxime 327, 359 cell separation by central thermodilution 178 direct Flick 188 Doppler ultrasound 184 indicator dilution 182 peripheral thermodilution 307, 309 clopidogrel 276 \200\2237, 391 clotting disorders 470 coagulants 322 coagulation centrifugation 114 180 central venous catheter pulse contour analysis 186 thoracic bio-impedance 168, 170, 172 central venous parenteral feeding route 130 monitoring 222 cocaine poisoning 532 188 thoracic reactance 188 INDEX 661 clinical governance 22 communication 18 \201 re safety 16 medicolegal aspects 20 outreach support 8 patient safety 14 SAPS score 30 scoring systems 26 SOFA score (Sequential diamorphine 305, 307, codeine 297, 305 colitis 420 colloid osmotic pressure 238 391, 395 diarrhea 408 diazepam 309, 313, 443, 445 diclofenac 303 digoxin 265, 272 273 dihyd rocodeine 305 diltiazem 391 direct Fick 188 direct thrombin inhibitors 319 colloids 246 colorimetric devices 146 coma 438 comfort 624 communication 18 compartment Organ Failure Assessment) 32 \200\2233 survivor follow-up 12 trauma score 34 see also Criti cal Care Unit syndrome 612 disease transmission 248 disposables, routine changes of 550 computerized tomography (CT): scan 158 severity index 425 confusion assessment Critical Care Unit 22 disseminated intravascular coagulation (DIC) 248 admission criteria 10 layout 2 staf \201 ng (medical) 4 staf \201 ng (nursing) 6 cross-in fection 544 crystalloids 242 crystal nephropathy diuretics 280, 495 dobutamine 265, 381, 395 dopamine 265, 269, 282, method 443 coning 454 consent and agreement 20 continuous positive airway pressure (CPAP) 58, 70 contr ol of infection: cross-infection 544 dangerous pathogens 548 human immunode \201 ciency 381, 395 dopexamine 265, 267 Doppler ultrasound 184 dorsalis pedis artery 166 doxapram 256 \200\2237 doxycycline 569 dressing techniques 138 drotrecogin alfa 332 drugs and cardiac arrest 340 drugs and metabolic acidosis 502 dye dilution 182 dynamic measurement 150 dyspnoea 346 400, 402 cyanide 534 cyclizine 293 virus 546 isolation 544 microbiological D dabigatran 318 dalteparin 319 damping errors 164 danaparoid 319 dangerous pathogens surveillance 544 staff measures (universal precautions) 544 visitors 544 conversion factors 33 cooling techniques 100 co-oximeter 152 Cori cycle (lactate-glucose 548 data collection 24 D-dimers 222 dead space to tidal volume ratio (Bohr equation) 146, 148 \200\22349 E early warning scoring between systems 8, 9 liver and muscle) 237 echocardiography 192, corneal re \202 exes 652 coronary 392 death and the dying patient 651 eclampsia 634 ecstasy poisoning 530 electrical cardioversion revascularisation techniques 104 brain stem death 652 organ/tissue donor, \200\230coronary steal \200\231 94 \200\2235 phenomenon 276 coronary syndrome, acute 388, 390 potential, care of 656 electrocardiogram withdrawal and withholding treatment 654 decision-making skills 4 deliberate harm 14 deliri um 442 dependency levels 11 derived indices 180 dexamethasone 314 \200\22315, (ECG) 162, 392, 600 electrocution 608 electroencephalogram (EEG)/cerebral function monitoring (CFM) 204 Coroner 20, 21 corrosives 536 corticosteroids 314, 328, 332, 362, 495 cortisone 329 co-trimoxazole 327, electrolytes 212, 482, 510, 610 enalapril 395 encephalitis 446 endocardial electrode placement 98 endoscopy, upper 359, 567 cough 352 re \202 ex 652 Cox-2 inhibitors 302 creatinine 210 clearance 210 329, 329 dexmedetomidine 302 \200\2233, 308, 309 dextran 246, 401 diabetic emergencies, hyperosmolar 512 diabetic ketoacidosis 510 dialysis, general indications gastrointestinal 120 critical care organization and management 01 endotracheal intubation 42 APACHE scoring 28 audit 24 endotracheal ventilation 364 enoxaparin 319 for 403 662 INDEX gut motility agents 294 H2 blockers and proton pump inhibitors 286 \202 udrocortisone 329, enoximone 265, 267, 395 enteral feeding and 332, 560 \202 uids 241 drainage tubes 122 enteral nutrition 128 eosinophilia 220 ephedrine 268 \200\2239 epidural analgesia 306 epinephrine: balance 362 blood products 250 blood transfusion 248 challenge 342 colloids 246 crystalloid s 242 management 510, 592 protein level 86 replacement 610 sodium bicarbonate 244 therapy, appropriate 238 sucralfate 288 gastrointestinal \202 uids, ion content of 243 gastrointestinal hemorrhage, upper 412 anaphylactoid reactions 578, 579 asthma 365 \200\2236 bronchodilators 254 \200\2235 cardiac arrest 340 heart failur e 395 hypotension 381 inotropes 265 sepsis and septic shock 560 vasopressors 269 gastrointestinal therapy techiques 117 enteral feeding and drainage tubes 122 Sengstaken-type tube 118 upper gastrointestinal endoscopy 120 \202 umazenil 256 \200\2237 foam dressing 138 forward \202 ow, decreased leading to poo r tissue perfusion 392 gelatin 246 gentamicin 327, 359, 447 Glasgow Coma Scale 26 \200\2237 glomerular disease 400 , 402 glycaemic control, fractional inspired oxygen epoprostenol 267, 330, 362 erroneous readings 178 errors and mishaps 20 erythromycin 295, 3 27, 359 esmolol 271, 383 ethylene glycol poisoning 538 (FIO2) 46 full blood count 220 fungi 226 furosemide 281, 314 \200\22315, 395 tight 132 glyceryl trinitrate (GTN) 277, 383, 391, 395 Goodpasture \200\231s syndrome 574 G gag re \202 ex 652 ganciclovir 327, 359 gas exchange 362 gas tonometry 196 gastric conte nts, aspiration exposure to infection 546 extracellular \202 uid (ECF) volume 486, 486 \200\2237 extracor poreal carbon dioxide removal (ECCO2R) 78 graft versus host disease (GVHD) 630 granisetron 293 Guillain-Barr syndrome 440, 440, 456 extracorporeal membrane gut motility agents 294 gut tonometry 196 of 374 oxygenation (ECMO) 78 \200\2239 extracorporeal respiratory support 78 gastric emptying 520 gastric irritation 406 gastric stasis 406 gastrointestinal bleeding, H H2 blockers 286 H5N1 570 hematological lower 420 gastrointestinal extravascular lung water measurement 156 disorders 405 abdominal sepsis 422 bleeding varices 414 bowels, failure to open 410 diarrhea 408 gastroin testinal disorders 467 anemia 472 bleeding disorders 468 clotting disorders 470 haemolysis 476 platelet disorders 478 sickle cell disease 474 hematological drugs 317 F F.H. 15 fat embolus 377 feed composition 128, 130 femoral artery hemorrhage, upper 412 cannulation 166 intestinal bleeding, lower anticoagulants 318 coagulants and fenestrated tubes 81, 81, 81 fentanyl 304, 305, 306, 307 fetal delivery, early 634 \201 b reoptic and colitis 420 intra-abdominal bowel perforation and obstruction 418 anti \201 brinolytics 322 thrombolytics 320 hematological management bronchoscopy 88 oesophageal and amniotic \202 uid embolus 640 \201 brin degradation products 222 \201 lter blood \202 ow 110 \201 re safety 16 \201 xed establishment 6 \202 ange tubes, adjustable 81 \202 ow monitoring 392 \202 u cloxacillin 327, 359, 447 \202 uconazole 327 \202 ucytosine 327, 447 perforation 416 pancreatitis 424 vomiting/gastric stasis 406 hematological management and trauma 582 gastrointestinal drugs 285 hemorrhage 172 haemo(dia) \201 ltration 108, antacids 290 anti-constipation agents 298 anti-diarrhoeals 296 anti-emetics 292 110, 403 haemodialysis 522 haemodynamic complications 56 INDEX 663 hyperglycaemia 508, 510 hyperin \202 ation 90 hyperkalaemia 402, 488 hyperlactataemia 502 hypernatraemia 484 hyperoncotic colloids 246 hyperosmolar diabetic emergencies 512 systemic in \202 ammation/ multi-organ failure 556, 558 toxic epidermal necrolysis 576 haemodynamic effects of cardiovascular drugs 265 haemodynamic management of renal failure 402 haemodynamics and treatment of infection 554 vasculitis 574 viral haemorrhagic fever positive end expiratory pressure 66 hemoglobin (Hb) 152, 220 haemolysis 476 haemolytic crisis 474 haemolytic uraemic syndrome 4 00 haemoptysis 372 hemorrhage: hypertension 382 hyperthermia 606 hypoadrenal crisis 516 hypocalcaemia 496 hypoglycaemia 50 6 hypokalaemia 490 hypomagnesaemia 492 hyponatraemia 486 hypophosphataemia 498 hypotension 380, 579 hypotensive agents 270 hypothermia 100, 600 hypovolaemia 398, 484 (VHF) 570 see also control of infection in \202 ammation see infection and in \202 ammation in \202 ammatory bowel disease 420 intracranial 448 post-partum 638 subarachnoid 450 upper inhalation injury 374 inhaled poisons 534 injury severity score (ISS) 34 inotropes 264 inot ropic support 380 inspiratory:expiratory gastrointestinal 412 haemothorax 172, 370 haemotological urinalysis (I:E) ratio 46 inspiratory \202 ow 46 inspiratory pressure support (Bird ventilator) 90 i nspiratory support 76 insulin therapy, intensive 132 tests 233 haloperidol 308 \200\2239, 443 head injury 586, 588 heart block 386 heart failure 392, 394 heart rate or rhythm, changes in 162 heavy metals 401 HELLP syndrome 636 heparinoids 318 \200\22319 heparin 276, 318 \200\22319, 377 hepatic blood \202 ow markers 218 hepatic dam age markers 218 hepatic disorders 427 I ibuprofen 303 ileus 406 imaging, respiratory 158 imipenem 327 immobilization and spinal inter-hospital transportation cord injury 590 immune reconstitution syndrome (IRS) 566 immunoglobulin (IV Ig) 332 immunom odulatory by air 648 inter-hospital transportation by road 646 intermittent positive pressure ventilation: therapies in sepsis 332 adjustment of ventilator 50 immunosuppression 356 impaired gas exchange 626 indicator dilution 182 indomethacin 303 inf arction, complicated 390 infarction, assessment of weaning 60 complications of ventilation 56 hepatic encephalopathy 432 jaundice 428 liver failure, acute 430 liver failure, chronic 434 hepatic encephalopathy description of ventilators 46 failure to deliver ventilation 54 failure to tolerate ventilation 52 uncomplicated 390 infection and in \202 ammation 432 hepatitis B 226 high frequency jet ventilation 62 172, 543, 584 anaphylactoid modes of ventilation 48 weaning techniques 58 intermittent \200\230T \200\231 piece 58 int erstitial pneumonitis 572 intestinal bleeding, reactions 578 HIV 226, 546 and burns 594 diagnosis of infection 552 disposables, routine changes of 550 related disease 566 household chemicals poisoning 536 hydralazine 267, 383, 635 hydrocolloi ds 138 hydrocortisone 329, 332 lower 420 H5N1 570 HIV-related disease 566 malaria 568 multi-resistant intra-abdominal bowel perforation and obstruction 418 anaphylactoid reactions intra-abdominal 578, 579 asthma 365 infection and infections 562 necrotising fasciitis 564 and neutropaenia 628 and pyrexia 602 rheumatic dis orders 572 SARS 570 sepsis and septic shock, treatment of 560 pressure, raised 614 intra-aortic balloon counterpulsation 102 in \202 ammation 560 intracranial hydrogels 138 hydroxyethyl starch 246 hypercalcaemia 494 hyperchloraemia 502 hemorrhage 448 intracranial pressure 44, 200, 454, 588 664 INDEX linezolid 327, 359 lisinopril 395 liver: intra-hospital hypomagnesaemia 492 hyponatraemia 486 hypophosphataemia 498 metabolic acidosis 502 metaboli c alkalosis 504 thyroid emergencies 514 metabolic management of transportation 644 intravascular catheters 550 intravenous immunoglobulin failure, acute 430 failure, chronic 434 function tests 218 transplantation 524 (IV Ig) 564 ipratropium bromide 254 \200\2235, 365 ischaemic/infarcted bowel 420 L-NG-monomethyl arginine renal failure 402 (L-NMMA) 268 metabolic myopathies 440 metabolic therapy see lobe/segment, collapsed 352 loperamide 297 lorazepam 309, 313, 445 low air loss bed 140 low T3 syndrome 514 lung recruitment 72 lung volumes and capacities iso \202 urane 254, 308, 366 isolation 544 isosorbide dinitrate 277, nutrition and metabolic therapy 391, 395 itraconazole 327 methanol poisoning 538 methionine 524 methoxamine 268 \200\2239 methylprednisolone J jaundice 248, 428 jugular venous bulb saturation 202 149, 352 329, 567 lupus pleurisy 572 lymphocytosis 220 lymphoma 630 lymphopaenia 220 methylthioninium chloride 268, 269 metoclopramide 293, 295 metolazone 281 metoprolol 383 metronidazole 327, 359 microatelectas is 352 microbiological K ketamine 254 \200\2235, 302, M macroatelactasis 352 magnesium 214, 254 \200\2235, 303, 366 ketoacidosis 502 ketorolac 303 surveillance 544 microbiological urinalysis 340, 385, 635 sulfate 273, 312, 313, tests 233 365, 445 malaria 568 malnutrition 127 management skills 4 mannitol 281, 314 \200\22315 manu al ventilation 338 mechanical ventilator 364 microvascular circulation L labetalol 271, 383, 635 laboratory monitoring 209 antibiotic assays 226 \200\2237 bacteri ology 224 calcium 214 cardiac function tests 216 coagulation visualization 194 midazolam 308 \200\2239, 445, 443 milrinone 265, 267, 395 mini-tracheotomy 82 miscellaneous drugs 325 antimicrobials 326 corticosteroids 328 immunomodulatory assist-controlled (ACMV) 48, 48, 48 classi \201 cation 46 controlled (CMV) 48, 48 setting up 46 therapies in sepsis 332 prostaglandins 330 rituximab 334 monitoring 222 creatinine 210 creatinine clearance 210 electrolytes 212 full blood count 220 fungi 226 liv er function tests 218 magnesium 214 phosphate 214 plasma ranges, normal 211 serology 226 \200\2237 toxicology 228 urea 210 viral culture 226 lactate 206, 236 lactic acidosis 236 la ryngeal oedema 579 left ventricular (LV) stroke medicolegal aspects 20 membrane \201 ltration 114 meningitis 446 meropenem 327 metabolic acidosis 154, molecular detection blood samples 224 monitoring, miscellaneous 231 calorimetry, indirect 234 colloid osmotic pressure 238 502, 610 metabolic alkalosis 154, 504 lactate 236 urinalysis 232 metabolic disorders 481 acid-base principles 500 diabetic ketoacidosis 510 electrolyte morphine 304, 305, 307, 443 Mount Vernon formula 593 multidisciplinary team communication 1 8 multi-organ dysfunction syndrome (MODS) 32, 556 management 482 hypercalcaemia 494 hyperglycaemia 508 hyperkalaemia 488 hypernatraemia 484 h yperosmolar diabetic emergencies 512 hypoadrenal crisis 516 hypocalcaemia 496 hypoglycaemia 506 hypokalaemia 490 multi-organ failure work index 177 556, 558 lepirudin 318 \200\22319 leukemia 630 levosimendan 265, 395 lidocaine 272 \200\2233, 303, muscle relaxants 310, 366, 440 myasthenia gravis 440, 458 385, 391 myocardial infarction 390 INDEX 665 intracranial pressure monitoring 200 jugular venous bulb saturation 202 pre-eclampsia and eclampsia 634 myopathy, critical illness 460 myxoedema coma 514 octaplex 323 octreotide 415 oesophageal N N-acetylcysteine 431, 524 naloxone 256 \200\2237 narcotics 401 nasoduodenal/nasojejunal lactate 206 near-infrared spectroscopy perforation 416 (NIRS) 206 oliguria 398 omeprazole 286 \200\2237 oncological critical care 623 neuromuscular disorders, critical care 460 chemotherapy and tube 122 neuropathy, critical illness 460 neuroprotective agents 314 radiotherapy, effects of 626 nasogastric tube 122 nasopharyngeal airway 40 near-drowning 610 near-infrared leukemia/lymphoma 630 neutropaenia and infection 628 pain and comfort 624 neutropaenia 220, 628 neutrophilia 220 nicorandil 276 \200\2237 nifedipine 267, 271, 277, spectroscopy (NIRS) 194, 206 ondansetron 293 opioid analgesics 304 opioid poisoning 526 organic solvents 401 organophosp hate poisoning 540 organ/tissue donor, nebulised drugs 254 necrotising fasciitis 564 neostigmine 459 nephrotoxins 400 \200\2232 ne phro-urological urinalysis 391, 635 nimodipine 314 \200\22315 nitrates 267, 271, 276 nitric oxide 258, 267, 362 nitrogen requir ements 126 nitrous oxide 302 non-invasive respiratory tests 233 nesiritide 267 neurological disorders 437 potential, care of 656 orogastric tube 122 oropharyngeal (Guedel) botulism 464 coma 438 delirium 442 Guillain-Barr support 76 non-opioid airway 40 analgesics 302 non-steroidal anti- outreach support 8 oxygen: syndrome 456 in \202 ammatory drugs (NSAIDs) 302