Search

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.

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.

Aim: In the current climate of medical education, there is an ever-increasing demand for and emphasis on simulation as both a teaching and training tool. The objective of our study was to compare the realism and practicality of a number of artificial blood products that could be used for high-fidelity simulation. Method: A literature and internet search was performed and 15 artificial blood products were identified from a variety of sources. One product was excluded due to its potential toxicity risks. Five observers, blinded to the products, performed two assessments on each product using an evaluation tool with 14 predefined criteria including color, consistency, clotting, and staining potential to manikin skin and clothing. Each criterion was rated using a five-point Likert scale. The products were left for 24 hours, both refrigerated and at room temperature, and then reassessed. Statistical analysis was performed to identify the most suitable products, and both inter- and intra-rater variability were examined. Results: Three products scored consistently well with all five assessors, with one product in particular scoring well in almost every criterion. This highest-rated product had a mean rating of 3.6 of 5.0 (95% posterior Interval 3.4-3.7). Inter-rater variability was minor with average ratings varying from 3.0 to 3.4 between the highest and lowest scorer. Intrarater variability was negligible with good agreement between first and second rating as per weighted kappa scores (K = 0.67). Conclusion: The most realistic and practical form of artificial blood identified was a commercial product called KD151 Flowing Blood Syrup. It was found to be not only realistic in appearance but practical in terms of storage and stain removal.

Visual inspection of a patient's urine has long been used by physicians, with colour recognised as having important clinical implications. In this review the authors will revisit this ancient pastime with relevance to contemporary medical practice.

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.