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Many individuals suffering from acute or progressive neurologic problems are managed in intensive care units. The capacity for these patients to exert autonomy regarding their own treatment is frequently compromised. Disease processes may impair consciousness and lucidity. Similarly, this may result from drugs, most frequently sedatives and analgesics that are necessitated by the treatments they are receiving, such as mechanical ventilation. This article will address the ethical and legal issues surrounding withdrawal of therapy, as they pertain to patients managed in intensive care units. Contemporary principles guiding clinicians’ decision making will be reviewed, followed by concerns and issues regarding common sources of conflict and misconception between patients, their families and healthcare professionals.

Summary Non-invasive positive pressure ventilation (NIV) is now widely used for a variety of chronic neuromuscular diseases, and available evidence demonstrates improved quality and quantity of life. Clinicians should be aware of the natural history of each neuromuscular disorder in order to make informed decisions about life-prolonging therapies in the intensive care setting. Attention to co-morbidities and reversible causes of exacerbations of respiratory failure are important given that these are often treatable. Nutritional factors play an important role in patients receiving NIV. End of life planning should be discussed with all patients requiring non-invasive ventilation.

Summary Parkinson's disease (PD) is a common neurodegenerative disorder, occurring in at least 1% of patients older than 65 years of age and characterized by bradykinesia, rigidity, and tremor. Parkinsonism is a broad term for patients with PD and Parkinson's like disorders. Due to the aging population, the number of patients admitted to the intensive care unit (ICU) with PD or disorders with Parkinsonism is expected to rise in the future. For optimal ICU care, PD co-morbidities of memory impairment, aspiration, and dysautonomia require special attention. Withdrawal of dopaminergic medications in the perioperative state or ICU can lead to worsened PD symptoms, chest wall rigidity complicating ventilator management, and a severe hyperpyrexia, rigid, encephalopathic state termed neuroleptic malignant syndrome (NMS). PD patients are also sensitive to antipsychotic and antiemetic medications, which can exacerbate rigidity and aspiration. Elderly patients with PD are more sensitive to sedative medications and more susceptible to develop post-operative or ICU delirium, which has increased morbidity and mortality. PD patients are at increased risk of increased perioperative aspiration pneumonia and its associated morbidity and mortality. Specialized ICU management strategies for patients with PD are described.

Brain death commonly occurs after a devastating central nervous system (CNS) injury from head trauma or stroke. Severe brain injury and brain death create a variety of extra-cerebral organ manifestations including neuroendocrine hormone deficiencies, systemic inflammatory response syndrome (SIRS), neurogenic pulmonary oedema (NPE), myocardial stunning, as well as electrolyte and immunologic derangements. Spinal-mediated reflexes after brain death may be alarming to medical staff and families alike, and proper recognition and counselling to the family is necessary to prevent further emotional turmoil and doubt against the diagnosis of brain death. The challenge for the intensive care unit (ICU) physician is maintaining adequate organ perfusion and metabolism in brain-dead patients who eventually become organ donors. Due to the potential benefit from organ donation, maximal ICU management strategies should be employed to maintain viable organs until brain death is confirmed and the patient's wishes for organ donation can be expressed through family or documentation. Optimal ICU management of brain-dead patents who become organ donors increases the opportunity for organ transplantation and provides donation of organs previously not spared.

Summary Weakness is a common problem in patients requiring intensive care unit management. Critical illness polyneuromyopathy is a useful term to describe the acquired neuropathy and/or myopathy that develops in the setting of critical illness. There is a broad differential diagnosis and although most cases can be diagnosed clinically, a range of investigations may be required. The principal risk factors are systemic inflammatory response syndrome (particularly due to severe sepsis), corticosteroid and neuromuscular blocking drug administration and hyperglycaemia. Treatment remains largely supportive, emphasizing the importance of preventative strategies. This article will answer common questions pertaining to critical illness weakness.

Cardiac surgery is a relatively new speciality which has burgeoned from its nascent state in the 1960s to a mammoth industry, such that over 1,000,000 cardiac procedures are conducted in the US on an annual basis.1 The development of safe cardiopulmonary bypass and the surgical techniques which it facilitated saw a huge rise in coronary and valve surgery over the subsequent 30 years. However, the “bread and butter” of cardiac surgery remained relatively unchanged despite the advent of off-pump bypass and use of arterial grafts until the last 10–15 years. Interventional cardiology, changing social views on what constitutes “too old” or “too sick”, improved intensive care and an increased use of mechanical assist devices such as intra-aortic balloon pump devices has changed the face of cardiac surgery. The increased uptake of percutaneous coronary interventions (PCI) since the advent of devices such as drug-eluting stents has all but removed the simple single vessel coronary graft for the cardiac operating list. As PCI devices improve, more and more studies comparing CABGs to PCI with stents are being reported, showing similar results in terms of death, MI and stroke, and whilst stents are associated in these studies with an increased need for re-vascularization, this gap is narrowing.2 The cardiac surgeon and cardiac anaesthetist are therefore being presented with octogenarians with poor left ventricular function and the associated organ dysfunction commonly seen in this age group. Paediatric patients, many of whom would not have previously survived birth, are now being presented for consideration of surgery in the first weeks post birth. Children and adults are supported on ventricular assist devices for many months or years, either as bridging or destination therapy. These patient groups are the sickest, frequently with the most to gain from a successful outcome, but occupy more ICU bed days, and many more health care pounds and dollars. The care pathway of the un-complicated post cardiac surgery patient is clear and generally straight, with a supervisory eye being the main function of the intensivist in the post operative period. However, as the patients become sicker and older (or younger in the paediatric population), and pre-operative organ dysfunction becomes the rule rather than the exception, the close collaboration of surgeon, intensivist, anaesthetist and perfusionist becomes key in the final discharge of these patients from hospital. A clear understanding of pre-operative risks, intraoperative procedures and post operative organ support are essential for the optimal result for the patient. This issue has chosen a number of fields associated with “high-end” cardiac surgery. It is by no means exhaustive, but reflects the major changes as they have impacted the critical care environment over the past decade. We have included a review on ventricular assist devices as recent data confirms their efficacy and improvement in survival in patients with severe heart failure, a condition whose incidence increases with each passing year. Some of the articles are reviews of a specific field, and some “tricks” or “pearls” that we wished we had learned many years ago. The articles are the combined work of intensivists, anaesthetists and cardiac surgeons, and the issue aims to be a practical guide augmented with recent data and evidence, rather than an isolated academic precis.