Death and dying

This chapter discusses death and dying, and includes discussion on confirming death using neurological criteria (brainstem death), withdrawing and withholding treatment, organ donation after brain death (DBD), and organ donation after circulatory determination of death (DCD). Death is common in the intensive care unit (ICU) and it is important to identify patients whose condition meets the criteria for brainstem death testing as well as patients where continued treatment is not considered to be in their overall best interests. Confirming death using neurological criteria allows the relatives to be presented with the certainty of a diagnosis of death whether organ donation is possible or not. Decisions to withraw treatment are common in the ICU and are associated with approximately 50% of all deaths in the ICU. The decision is made by the multidisciplinary team in consultation with the patient’s relatives and taking into account the patient’s values and preferences. In both situations the possibility of organ donation should be considered and explored, and, when it is a possibility, it should be routinely offered to the relatives as an end-of-life care option.

Trauma and burns

This chapter discusses trauma and burns and includes discussion on initial management of major trauma (ABCDE), head injury (both primary and secondary, but also clinical management, general intensive care unit care, and specific treatment of raised intracranial pressure), spinal trauma, chest trauma, pelvic trauma, the fluid management of burns and the general management of burns, and penetrating trauma. The concepts of permissive hypotension, ongoing resuscitation, and injury severity scores are discussed, together with the importance of the tertiary survey. The need for treatment in a centre that can deal with all aspects of multiple trauma and the rapid transfer to such a centre is emphasized. Burns treatment includes the effect of inhalational injury to the airway. The need for treatment in a centre that can deal with all aspects of multiple trauma and the rapid transfer to such a centre is emphasized.

Respiratory drugs

This chapter discusses respiratory drugs and includes discussion on bronchodilators (describing β‎2-agonists, anticholinergic agents, and xanthine derivatives), nitric oxide (history, biochemistry, clinical use of inhaled nitric oxide, administration of inhaled nitric oxide, adverse effects of inhaled nitric oxide, and adjunctive therapies), mucolytics (properties of mucus, types of mucolytics, clinical applications, and side-effects), and helium–oxygen gas mixtures (including nomenclature, rationale, indications, expected effects, presentation, face mask administration, nebulization, patient monitoring during therapy, stopping helium–oxygen therapy, indications for helium–oxygen mask ventilation, indications for helium–oxygen intermittent positive pressure ventilation (IPPV) via endotracheal or tracheostomy tube, patient monitoring during IPPV therapy, stopping helium–oxygen therapy, and published trials).

Neurological monitoring

Dealing with neurological critically ill patients is one of the most challenging situations in intensive care. The range of conditions can go from carbon dioxide narcosis to status epilepticus or hypoxic or traumatic brain injuries. The key difficulty is the neurological assessment of these patients while they require general anaesthesia. This chapter discusses neurological monitoring and includes discussion on intracranial pressure (ICP) monitoring (including indications for ICP monitoring, methods of measuring ICP, complications of ICP monitoring, and ICP in normal and pathological conditions), intracranial perfusion (regulation of cerebral perfusion and measurement of cerebral blood flow), electroencephalogram (EEG) and cerebral function analysing monitoring (CFAM) (EEG, cerebral function monitors (CFM)/CFAM, EEG terminology, and clinical use in the intensive care unit), and other forms of neurological monitoring (tissue metabolism, cerebral blood flow and metabolism, and peripheral nerve and muscle electrophysiology).

Intensive care unit organization and management

This chapter discusses ICU organization and management and includes discussion on consent on the ICU, rationing in critical care, ICU layout, medical staffing, ICU staffing (both nursing and staffing for supporting professions), fire safety in the ICU, legal issues and the Coroner, patient safety, Severity of Illness Scoring systems, comparison of ICUs, critical care disaster planning, health technology assessment, transfer of the critically ill patient, aeromedical evacuation, outreach and medical emergency teams, critical care follow-up, rehabilitation, and managing antibiotic resistance.

Shock

This chapter discusses shock and includes a definition and diagnosis, discussion on hypovolaemic shock (including causes of hypovolaemic shock, therapy, and the reperfusion phase), cardiogenic shock, anaphylactic shock (including pathophysiology), and pathophysiology of sepsis and multiorgan failure.

Gastrointestinal disorders

This chapter discusses gastrointestinal (GI) disorders and includes discussion on vomiting and gastric stasis/gastroparesis, gastric erosions, diarrhoea, upper GI haemorrhage (non-variceal), bleeding varices, intestinal perforation, intestinal obstruction, lower GI bleeding, colitis, pancreatitis, acute acalculous cholecystitis, splanchnic ischaemia, and abdominal hypertension (IAH) and abdominal compartment syndrome. The aim is to provide a summary of the extensive complex abdominal pathologies that can present to an intensive care clinician. Where appropriate, descriptions are provided on clinical presentation, epidemiology, diagnosis (including investigations), and management. Of note, the conditions covered can arise on the ward environment with subsequent requirement for intensive care, but they can also arise de novo on the intensive care unit itself, highlighting the need for intensive care clinicians to maintain a broad knowledge and understanding of their presentation and management.

Renal disorders

This chapter discusses renal disorders and includes discussion on prevention of acute kidney injury, including optimizing renal perfusion with the use of volume expansion, inotropic, vasopressor, and vasodilator medications; modulation of renal physiology, including renal metabolism, tubular obstruction, oxygen radical damage, and renal regeneration and repair. This chapter also discusses the diagnosis of acute kidney injury, including parameters of glomerular function, urine analyses, biomarkers, ultrasound, autoimmune profiling, and renal biopsy.

Respiratory disorders

This chapter discusses respiratory disorders and includes definitions, pathophysiology, and management strategies of upper airway obstruction, respiratory failure, pulmonary collapse and atelectasis, chronic obstructive pulmonary disease, and acute respiratory distress syndrome (diagnosis, general, and ventilatory management strategies). It also includes sections detailing pathophysiology and management of pneumothoraces, empyema, haemoptysis, inhalation injury, pulmonary thromboembolism, community-acquired pneumonia, hospital-acquired pneumonia, and pulmonary hypertension.

Nutrition

This chapter discusses nutrition and includes discussion on enteral nutrition (including discussion on enteral nutrition versus parenteral nutrition, how to feed, what to feed, and complications), nutritional assessment and requirements (including the role of the multidisciplinary team, nutritional assessment, and nutritional requirements), and parenteral nutrition (including when to start, how to feed, what to feed, and when to stop).