Cholescintigraphy in the critically ill

Critical review of cholescintigraphy in critically ill patients suggests the examination will not conclusively prove or disprove the diagnosis of acute cholecystitis. Of 17 scans performed in critically ill patients with clinical evidence of acute cholecystitis, 7 were true-negative, 1 was false-negative, 6 were false-positive, and 3 were nondiagnostic. Cholestasis and hepatocyte dysfunction, common in the critically ill, result in abnormal clearance of hepatobiliary radionuclide imaging agents, decreasing the usefulness of cholescintigraphy in this patient population. Diagnosing acute cholecystitis in a critically ill patient remains difficult.     

Electrolyte disorders in the critically ill

Electrolyte disorders are ubiquitous in the critically ill patient, and their identification and management are vital for the patient's safe care. This article provides a guide to the aetiology, analysis and management of major electrolyte disorders in the critically ill.     

Fungal infections in the critically ill

The successful management of invasive fungal infections continues to plague the clinician. They are associated with an unacceptably high morbidity and mortality, with reliable diagnostics a major issue. Although well described in the immunocompromised, especially haemato-oncology patients, there is no doubt that these infections are on the rise in the critically ill, intensive care patient. This article aims to examine and focus on the changing epidemiology, problems with diagnostics and the management of such life threatening sepsis.     

Sedation in the critically ill patient

Critically ill patients who require intensive care need effective analgesia and sedation to control potentially unpleasant symptoms, such as pain and anxiety. Analgesics and sedatives are also used to allow patients to tolerate nursing procedures and tracheal intubation as well as to aid mechanical ventilation. Metabolism of traditional opioids is dependent on organ function, which is abnormal among critically ill patients. The use of a score system to ensure sufficient but not excessive sedation should be mandatory. Sufentanil and remifentanil are more predictable opioids that are suitable for either sedation or analgesia in critically ill patients to achieve an adequate Ramsay score from 2 to 4.     

Electrolyte disorders in the critically ill

Electrolyte disorders are extremely common in the critically ill patient. Competent analysis and management of these is essential in providing quality intensive care. This article provides a review of and guide to aetiology, analysis, and management of the major electrolytes in the critically ill.     

Nutritional support in the critically ill

Nutritional support is a vital intervention in the critically ill that can adversely affect survival and morbidity. Many patients presenting to critical care have a degree of nutritional deficiency either due to chronic ill health or their presenting complaint and these have to be addressed. Critical illness itself affects the nutritional needs of patients, progressing from profound catabolism to a degree of anabolism and support must reflect these changes. Challenges exist in both the calculation of requirements and the provision of appropriate support, and the use of the multidisciplinary team is essential to provide high-quality support. Calculations of nutritional requirements are complicated both by the nature of critical illness and the limited access to sources of information. Nutritional support itself can cause morbidity, either via unrecognized refeeding syndromes, or by complications of the chosen route of support and an appreciation of the evidence base is essential to make the right choice for patients.     

Dyslipidemia in the critically ill patient

Dyslipidemia seen in the critically ill patient is a common disturbance, poorly recognized by physicians in this setting. Shock states, sepsis, multifactorial systemic inflammatory response syndrome and ischemia-reperfusion injury are associated with important metabolic changes that contribute to this disturbance. As a result, the lipid concentration, including cholesterol, high-density lipoproteins and apo-lipoprotein A-I, diminishes. Previous reports correlate the disturbance in lipids with a higher risk of infection, systemic inflammatory response syndrome, multiple organic dysfunction syndrome, and raised mortality. The use of reconstituted high-density lipoprotein may be a therapeutic alternative for the management of this entity.     

Cardiac arrhythmias in the critically ill

Arrhythmias are a common problem in the critically ill and they can have significant effects on patient outcome. They often require immediate and swift action and it is, therefore, essential that clinicians have a structured approach to the recognition and management of arrhythmias. Here, we provide a framework for the appropriate management of the more frequently encountered cardiac arrhythmias in critical care. We include the algorithms from the 2015 Resuscitation Council Guidelines for reference.     

Postoperative delirium in the critically ill

Acute confusional states (delirium) occur in up to 80% of patients in the intensive care unit. Delirium is an important independent prognostic determinant of hospital outcome, including duration of mechanical ventilation, nursing home placement, functional decline and death. Additionally, it may herald systemic diseases such as sepsis and multi-organ failure. Recently, a number of new screening instruments have been validated for the monitoring of delirium in non-communicative patients receiving mechanical ventilation. Critical care patients should be routinely assessed for delirium and treated immediately using available preventive and therapeutic measures, both pharmacological and non-pharmacological, to improve the clinical course.     

Adrenal failure in the critically ill

Three critically ill patients suffered multiple organ failure secondary to sepsis. Despite adequate supportive therapy and appropriate antibiotic cover, they failed to improve and required inappropriate inotrope support. They had not been treated with steroids or other drugs known to suppress adrenal function. Adrenal insufficiency was suspected. A random cortisol concentration and a short synacthen test demonstrated concentrations below the range expected in all three cases. High-dose steroid therapy was commenced with marked improvement in the short-term. However, in each case sepsis eventually caused death.      

Electrolyte disorders in the critically ill

Electrolyte disorders are ubiquitous in the critically ill patient. Abnormalities may provide clues to the diagnosis, severity and even prognosis of illnesses. Abnormal serum electrolytes can be a marker of total body electrolyte deficit or excess, or movement between compartments. Despite the morbidity and mortality associated with electrolyte disorders in critically ill patients, the evidence to guide management is limited. This article provides a guide to the aetiology, clinical features and management of major electrolyte disorders in the patients in the intensive care unit.     

Nutrition in the critically ill patient

Critically ill patients are hypermetabolic and have increased nutrient requirements. Although it is assumed that nutritional support is beneficial in this group of patients there are no well designed clinical trials to test this hypothesis. The rationale for nutritional support, therefore, is based upon clinical judgement. Although it is not known how long a critically ill patient can tolerate what is effectively starvation, the loss of lean tissue which occurs in catabolic patients (20-40 g nitrogen/day) suggests that depletion to a critical level may occur after 14 days. Total parenteral nutrition given to malnourished patients with gastrointestinal cancer for 7 to 10 days before surgery has been shown to decrease complications by about 10%. Wound healing and normal immune responses are dependent upon adequate nutrient intake, and it seems reasonable, therefore, to commence feeding as soon as possible. Earlier feeding may decrease length of stay and complication rates in both critically ill patients and following surgery. It has been shown in randomised controlled trials of both enteral and parenteral feeding in the critically ill, that current regimens are sub-optimal. Calorie intake was shown to be often considerably in excess of metabolic requirements alone, and variable study design has made comparisons impossible. Despite the lack of knowledge regarding even the most simple of nutritional requirements in these patients, the administration of specific micronutrients and specialised supplements has attracted attention. Again, many of these more recent studies are limited because of poor study design.     

Electrolyte disorders in the critically ill

Electrolyte disturbance is almost ubiquitous in the critically ill. Competent analysis and management are crucial in providing quality intensive care, as evaluation may provide an aid to the diagnosis, a marker of disease severity and recovery, while specific electrolyte derangement may require specific management. While many electrolyte abnormalities can be managed by simply increasing intake to reverse deficits and reducing intake and encouraging loss for excess levels, generalizing this approach is over-simplistic. Disturbed serum levels do not always reflect the total body stores of the electrolyte but may reflect a pathological process that requires specific definitive treatment. While established recipes for electrolyte replacement to correct abnormalities serve as a starting point, these cannot replace repeated clinical examination, and sequential measurement of the electrolytes. In this paper we provide a review of and a guide to the aetiology, analysis and management of the major electrolytes in the critically ill.