Rhabdomyolysis and acute renal failure in intensive care

The aetiology and pathophysiology of the complex clinical condition rhabdomyolysis are outlined here Rhabdomyolysis can be caused by a number of factors including excessive muscle activity, direct muscle injury, ischaemia and excesses of temperature Specific nursing care strategies, focusing on the pathophysiology of the condition, are proposed The priorities of care should centre on maintaining patient safety with monitoring of cardiovascular and respiratory systems and assessment of renal function     

Expanding intensive care medicine beyond the intensive care unit

Intensive care medicine probably requires the artificial boundaries of an intensive care unit to nurture and legitimize the specialty. The next major step in intensive care medicine is to explore ways of optimizing the outcome of seriously ill patients by recognizing and resuscitating them at an earlier stage. Some of these ways include better education of existing staff; earlier consultation; and automatic calling by intensive care staff to abnormalities identifying at-risk patients. Some of these interventions are currently being evaluated and results should soon indicate their relative effectiveness.     

Expanding intensive care medicine beyond the intensive care unit

Intensive care medicine probably requires the artificial boundaries of an intensive care unit to nurture and legitimize the specialty. The next major step in intensive care medicine is to explore ways of optimizing the outcome of seriously ill patients by recognizing and resuscitating them at an earlier stage. Some of these ways include better education of existing staff; earlier consultation; and automatic calling by intensive care staff to abnormalities identifying at-risk patients. Some of these interventions are currently being evaluated and results should soon indicate their relative effectiveness.     

Bronchoscopy in the intensive care unit

The development of the flexible, fiberoptic bronchoscope has made bronchoscopic examinations possible in ICU patients undergoing mechanical ventilation. Over the years, the number of such procedures has greatly increased, with both diagnostic and therapeutic objectives, such as performing difficult intubation, management of atelectasis and hemoptysis, diagnosis of nosocomial pneumonia in ventilated patients, and early detection of airway lesions in selected situations, such as high-frequency ventilation. The complication rate can be kept low if the endoscopist has a precise knowledge of the many pathophysiological and technical facets particular to bronchoscopy under these difficult conditions. This article reviews some of these aspects, in the light of our personal experience.     

Sedation in the intensive care unit

OBJECTIVE: To describe the goals of sedative use in the intensive care unit and review the pharmacology of commonly used sedative drugs as well as to review pertinent publications in the literature concerning the comparative pharmacology of these drugs, with emphasis on outcomes related to sedation and comparative pharmacoeconomics. DATA SOURCES: Publications in the scientific literature. DATA EXTRACTION: Computer search of the literature with selection of representative articles. SYNTHESIS: Proper choice and use of sedative drugs is based on knowledge of the pharmacology of commonly used agents and is an essential component of caring for patients in the intensive care unit. The large variability in pharmacokinetics and pharmacodynamics in the critically ill make it difficult to directly compare agents. Midazolam provides rapid and reliable amnesia, even when administered for low levels of sedation. Propofol may be useful when deeper levels of sedation and more rapid awakening are required. Lorazepam can be used for long-term sedation in more stable patients if rapidity of effect is not required. Further investigation in assessment of depth of sedation in the critically ill is needed. Continued study of costs, side effects, and appropriate dosing strategies of all sedative agents is needed to answer questions not sufficiently addressed in the current literature. Conclusion: An individualized approach to sedation based on knowledge of drug pharmacology is needed because of confounding variables including concurrent patient illness, depth of sedation, and concomitant use of analgesic agents. (Crit Care Med 2000; 28:854-866) KEY WORDS: sedation; anxiolysis; critical care; midazolam; lorazepam; propofol; benzodiazepines; intensive care unit; pharmacoeconomics; critical illness     

Delirium in the intensive care unit

Delirium, an acute and fluctuating disturbance of consciousness and cognition, is a common manifestation of acute brain dysfunction in critically ill patients, occurring in up to 80% of the sickest intensive care unit (ICU) populations. Critically ill patients are subject to numerous risk factors for delirium. Some of these, such as exposure to sedative and analgesic medications, may be modified to reduce risk. Although dysfunction of other organ systems continues to receive more clinical attention, delirium is now recognized to be a significant contributor to morbidity and mortality in the ICU, and it is recommended that all ICU patients be monitored using a validated delirium assessment instrument. Patients with delirium have longer hospital stays and lower 6-month survival than do patients without delirium, and preliminary research suggests that delirium may be associated with cognitive impairment that persists months to years after discharge. Little evidence exists regarding the prevention and treatment of delirium in the ICU, but multicomponent interventions reduce the incidence of delirium in non-ICU studies. Strategies for the prevention and treatment of ICU delirium are the subjects of multiple ongoing investigations.     

Arthritis in the intensive care unit

Acute arthritis in critically ill patients may be caused by local or systemic infection, by a flare of chronic joint disease such as rheumatoid or crystal-associated arthritis, or by less common entities such as hemarthrosis. Diagnosis requires analysis of synovial fluid, and appropriate treatment is based on its findings. Prompt diagnosis and treatment are usually necessary to prevent the significant morbidity associated with these conditions.     

Delirium in the intensive care unit

Delirium in the intensive care unit (ICU) is a complex, common, and problematic condition that interferes with healing and recovery. It leads to higher morbidity and mortality and extended hospital stays. The aging population older than 65, and more likely to develop delirium, is the fastest growing population in the United States and is increasingly seen in the ICU. Delirium is often unrecognized and misdiagnosed, which leads to mistreatment or lack of appropriate treatment. This article discusses the definition of delirium, pathogenesis, clinical practice guidelines, newer assessment tools for ICU, and nursing interventions directed toward prevention and early identification of delirium.     

Statins in the intensive care unit

PURPOSE OF REVIEW: Statins are effective lipid-lowering agents used extensively in medical practice. This review summarizes the evidence for statin treatment of cardiovascular patients in the intensive care unit and briefly discusses the role of statins in prevention and treatment of sepsis as a potential future application of statins in critical care. RECENT FINDINGS: Recent studies have extended the use of statin therapy to the acute manifestations of cardiovascular disease and have suggested cholesterol-independent therapeutic benefits, termed pleiotropic effects, which have added a wide scope of potential targets for statin therapy. SUMMARY: Statin therapy should be continued in intensive-care patients in whom statin therapy is warranted due to underlying cardiovascular disease or significant risk thereof. In acute coronary syndromes, statin therapy should be initiated within 24-96 h regardless of pretreatment cholesterol levels. Patients undergoing vascular surgery should receive peri-operative statin therapy. Placebo-controlled clinical trials are required to consolidate the experimental and observational evidence for prevention and treatment of sepsis.     

Sleep in the intensive care unit

Abnormalities of sleep are extremely common in critically ill patients, but the mechanisms are poorly understood. About half of total sleep time occurs during the daytime, and circadian rhythm is markedly diminished or lost. Judgments based on inspection consistently overestimate sleep time and do not detect sleep disruption. Accordingly, reliable polygraphic recordings are needed to measure sleep quantity and quality in critically ill patients. Critically ill patients exhibit more frequent arousals and awakenings than is normal, and decreases in rapid eye movement and slow wave sleep. The degree of sleep fragmentation is at least equivalent to that seen in patients with obstructive sleep apnea. About 20% of arousals and awakenings are related to noise, 10% are related to patient care activities, and the cause for the remainder is not known; severity of underlying disease is likely an important factor. Mechanical ventilation can cause sleep disruption, but the precise mechanism has not been defined. Sleep disruption can induce sympathetic activation and elevation of blood pressure, which may contribute to patient morbidity. In healthy subjects, sleep deprivation can decrease immune function and promote negative nitrogen balance. Measures to improve the quantity and quality of sleep in critically ill patients include careful attention to mode of mechanical ventilation, decreasing noise, and sedative agents (although the latter are double-edged swords).     

Sedation in the intensive care unit

Although the administration of sedatives is a commonplace activity in the ICU, few guidelines are available to aid the clinician in this practice. The first principle of sedative administration is to define the specific problem requiring sedation and to rationally choose the drug and depth of sedation appropriate for the indication. Next, the clinician must recognize the diverse and often unpredictable effects of critical illness on drug pharmacokinetics and pharmacodynamics. Failure to recognize these effects may lead initially to inadequate sedation and subsequently to drug accumulation. Drug accumulation may result in prolonged encephalopathy and mechanical ventilation and may mask the development of neurologic or intra-abdominal complications. Daily interruption of continuous sedative infusions is a simple and effective way of addressing this problem. A glossary of sedative drugs commonly used in the ICU is included in this review.